BILOXI, Miss. (WLOX) - Results of an investigation into the death of a patient at the Biloxi VA were released this week, determining that staff in the hospital’s behavioral health unit did not act quickly or follow procedure.
The VA Office of Inspector General began the investigation into the patient's death after concerns were reported that the hospital staff did not make resuscitation efforts in a timely manner.
A report by the OIG was released Tuesday, titled "Mismanagement of a Resuscitation and Other Concerns at the Gulf Coast Veterans Health Care System."
The report states that the patient died in 2017 less than 24 hours after being admitted to the behavioral health unit. The patient was under orders to be closely observed every 15 minutes. Staff were expected to conduct rounds to check on the patient and document the checks. At least one of those 15-minute checks was documented in the patient’s chart, despite video showing that a check was never made, said the report.
According to the report: "Upon finding the unresponsive patient, the healthcare inspection determined that staff at the VA did not not quickly assess the patient, act with a sense of urgency, alert the care team, immediately initiate basic life support, locate the nearest automated external defibrillator, or activate the community 9-911 emergency response system, all of which were required by policy."
Multiple RNs reported assessing the patient for several minutes, said the report. However, immediate resuscitation efforts were not made. While the OIG could not determine if those efforts would have been successful, the medical staff still had a duty to the patient to try and provide life-saving care, said the report.
“By not recognizing the patient’s acute medical emergency and not acting with a sense of urgency, the rounding nurse, the charge nurse, the assigned nurse, and the unit 25-A nurse were not practicing within their expected roles and duties to initiate and sustain resuscitation,” stated the report.
The physician on duty, which is known as a medical officer of the day or MOD, recorded in the patient's chart that a nurse examined the patient and deemed the patient to be dead. The MOD further documented telling the nurse that “if you have determined that the patient was dead then at this time, CRP [sic] would not likely be helpful.”
Additionally, the OIG found that the behavioral health unit did not maintain updated records of basic life-saving competency and training certifications completed by the RNs, which is against the facility's policy.
Undocumented communication when handing the patient off from the emergency department to the behavioral unit and an expired package of tubing on the behavioral health unit's emergency cart were also found during the OIG's inspection, according to the report.
Furthermore, the VA failed to notify the patient's family about the issues related to the patient's care. That disclosure - referred to as institutional disclosure - should be done to inform patients and their families any time there are substantive issues related to the patient's care, along with options for redress when appropriate. In this case, the OIG found that the VA had a duty to notify the patient's family since it could not be determined whether the patient died as a result of not having CPR.
The OIG says facility management removed the involved staff from patient care and discussed reporting the nurses to the state licensing boards. Even though some of those nurses retired or resigned after being removed, the OIG still recommends that their actions be reported to the state licensing board. Despite that recommendation, no documentation was found by the OIG showing that it had been reported yet.
The OIG made nine recommendations for emergency/code blue procedures, pronouncement of death, BLS competency and training (certification), patient health record documentation, documentation of behavioral health information on transfers of patients, emergency carts compliance, actions from fact-finding review, institutional disclosure, and critical care committee review of BLS events.
Gulf Coast VA Health Care System released a statement Wednesday saying the facility has instituted audits of emergency/code blue procedures in the acute inpatient psychiatry setting and incorporated them into nursing orientation practices and behavior health emergency procedures, designated behavior health nurses maintain basic life support competencies, instructed behavior health nurses currently assigned to acute psychiatry receive education on Veterans Health Administration Directive 2011-016 for pronouncement of deaths, audits of medical records of veterans transferred from the emergency department to acute psychiatry each month to ensure appropriate provider-to-provider communication and daily audits by management of use of emergency carts to ensure compliance.
To read the full report issued by the Department of Veterans Affairs Office of Inspector General, click HERE.