A Vallejo man lost his life after spending more than eight agonizing hours waiting for treatment at Kaiser Vallejo's emergency room. Francisco Delgadillo, 53, arrived at the hospital last December, experiencing severe chest pain.
Our Investigative Unit found that in the days and months prior to the incident, the facility’s emergency room nurses had complained about being chronically understaffed, as revealed in interviews with several ER nurses and a circulated petition.
A state and federal investigation, motivated by Delgadillo’s death, found several deficiencies at Kaiser Vallejo’s emergency department. It also revealed there were not enough nurses working that night and Delgadillo’s pain was not reassessed.
Despite his urgent condition, the father of four languished in the waiting area, and his pleas for medical attention went seemingly unheard.
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According to his family and the investigation’s findings, on Dec. 8, 2023, Delgadillo arrived at 3:44 p.m. and was given the initial tests and assessment, including an EKG, a check of his vital signs, and blood work. According to the medical report, the tests yielded normal results. At that time his family says he was assigned ticket number 29.
He was also triaged and identified as a ESl level 2 priority in the five-level triage scale, where ESI level 1 is the highest severity. ESI level 2 is a patient with an illness or injures that place them at high risk for deterioration, or signs of a time-critical problem that requires prompt attention, according to the hospital’s triage system.
Delgadillo's wife, Maria De La Luz Luna, says her family met Delgadillo in the waiting room and continuously asked hospital staff to reassess him. Delgadillo’s medical record shows his chest pain escalated from a level 7 to a level 10 as he sat in the emergency room’s waiting area.
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His son, Ulysses Delgadillo Luna, recalled the distressing scene, describing a waiting room filled with patients, none as visibly distressed as his father. “He was, holding tight on his shirt where his heart was. He was, like, struggling to sit on, the chair. He kept moving around. He was laying down on the floor,” Ulysses said.
The investigation’s reports indicate that at some point the family called 911 from the emergency room. But when paramedics arrived, they said there was nothing they could do since they were already at a hospital. One of the paramedics spoke to medical staff and Delgadillo was brought back to the EKG room, but was returned to the waiting room soon after, according to the review.
Tragically, around 11:30 p.m., after eight hours of waiting, Delgadillo collapsed in the hospital lobby and succumbed to cardiac arrest around midnight, according to his medical record. His family says he was just five numbers away from being called for treatment.
In the wake of the incident, investigations by both federal and state authorities were launched into Kaiser Vallejo's emergency department operations. The Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), and California’s Department of Public Health (CDPH) conducted a thorough review and identified eight deficiencies at Kaiser Vallejo’s ER, including failures in their emergency services and nursing services.
The investigation revealed the following findings about that night:
- The ER was described as “crazy busy” with 30-40 patients, but no certified nurse in the lobby to reassess them.
- The hospital’s governing body failed to maintain adequate staff and did not follow policy and procedures.
- The facility had no strategic plan for a patient surge, according to the review.
- The ER failed to reassess the patient every 2 hours after triage resulting in the patient’s cardiac arrest 8 hours after his arrival.
Emergency room nurses at the hospital told us they had reportedly raised concerns about insufficient staffing during a November in-person meeting and circulated a petition that was eventually signed by all staff members, demanding safe staffing at the facility—just three days before Delgadillo’s death.
Raquel Benito, representing the California Nurses Association for Kaiser Vallejo’s ER nurses, highlighted ongoing staffing challenges, stating that the department often operated with significantly fewer nurses than necessary, a particular challenge during the predictable winter surges. “When we're surging in winter surges, we need way more staff than that to be able to adequately care for patients,” Benito said.
In response to inquiries, Kaiser Permanente expressed condolences to the Delgadillo family and detailed improvements made since the incident, including adjustments to staffing models and escalation procedures. They emphasized compliance with regulatory standards but did not disclose specific staffing figures despite repeated requests.
Attorney Jeff Mitchell, representing the Delgadillo family, has initiated arbitration against Kaiser, alleging medical negligence in Delgadillo's death. He says the staff is not to blame, but Kaiser’s leadership is. He described the emergency department as historically underserved, understaffed, and undermanned.
“There are only two hospitals in that part of Solano County, and that's one of them. And a lot of that population there is uninsured or underinsured. They don't have a county hospital. So, in effect, Kaiser serves as a county hospital. And under federal law, they're required to give people care in the emergency room,” Mitchell said.
But Delgadillo was insured under a Kaiser policy, and his medical records indicate he had no previous heart problems. His friends and family describe him as a hardworking and happy man.
Kaiser Permanente would not say if any administrators were disciplined but affirmed it is now in compliance with federal and state requirements. It also said it consistently meets nurse staffing ratios. Though NBC Bay Area asked repeatedly, Kaiser Permanente did not provide the exact staffing numbers for Vallejo or other Bay Area emergency departments.
