The death of a patient inside the Biloxi VA hospital’s mental health unit has prompted an inspection report from the Department of Veterans Affairs’ Office of Inspector General.
Titled “Mismanagement of a Resuscitation and Other Concerns at the Gulf Coast Veterans Health Care System,” the report issued Tuesday details missteps by nurses and staff related to their actions, documentation and communication.
The death happened in late 2017, and the VA started an inspection Jan. 4 with a site visit from Jan. 9-11, 2018.
It started with the early-morning admission of a patient in their late 50s with a history of IV drug abuse, the report says. A week beforehand, the patient had been seen at the VA for the first time since 2006 and was assigned a primary care doctor.
The patient was admitted into the ER with self-inflicted stab wounds to both thighs, made during an episode of alcohol and cocaine intoxication in which the patient “freaked out.” The patient was admitted with an initial diagnosis of depression, substance abuse, “suicidal gesture” and lacerations that required stitches.
The patient tested positive for cocaine and alcohol, and was given a physical and heart exam with electrocardiogram.
The first ER doctor was unable to transfer the patient to a behavioral health unit, so care transferred to a second ER doctor after a shift change.
By that afternoon, the patient was admitted to one of two behavioral health units (A and B) with orders of close observation every 15 minutes. The patient was evaluated by a nurse practitioner, then again in the evening. The patient said “I’m alright” appeared calm and cooperative, and took medication, the nurse recorded.
The nurses’ log shows the patient was first noticed to be asleep starting at midnight. A camera in the hallway outside the room showed a nurse checking on the patient every 15 minutes, except at 12:45, when a check was documented but no nurse was seen outside the room.
The 1 a.m. check was seen on camera, but at 1:15 a.m., a nurse was unable to determine whether the patient was breathing, and could not see the chest rising and falling.
Instead of immediately performing CPR or investigating further, the nurse went back to the nurse’s station to tell the shift leader and “did not convey the information with a sense of urgency,” the report says.
Both headed back to the patient’s room, and shift leader, or charge nurse, used a cellphone to call a nurse from the other unit.
The second nurse did not find a pulse and saw the patient was not breathing.
The first nurse again went back to a nurse’s station to get a stethoscope and alert the nurse assigned to the patient, saying “we think (the patient) is dead.”
While the second nurse was alone with the patient, a time period of only 2 minutes, the nurse said they performed chest compressions and mouth-to-mouth resuscitation.
When the assigned nurse got to the room and saw second nurse standing at the head of the bed, they told the OIG they assumed CPR had already been performed.
When the nurse from the A unit arrived to the B unit’s nursing station, the remaining nurses at the station “were unaware of the charge nurse’s location or that an emergency was taking place.”
The A unit nurse arrived to the patient’s room where the three other nurses were, then left to notify the medical officer of the day (MOD), who said “no CPR,” and relayed that to the other three nurses.
The MOD documented time of death at 1:44 a.m. without seeing the patient. Only a doctor, not a nurse, can pronounce a death.
An autopsy listed the patient’s cause of death as sudden cardiac death due to cardiac arrhythmia (abnormal heart rhythm) and myocardial ischemia caused by cocaine use and high blood pressure.
But the OIG noted that it was “unable to determine whether initiating full resuscitation efforts would have been successful if employed at the time the patient was found unresponsive.”
The OIG found the staff did not:
- Quickly assess the patient,
- Act with a sense of urgency to a potential or actual emergency medical condition,
- Alert the care team of the emergency medical condition,
- Immediately initiate BLS (CPR) and locate the nearest AED (defibrillator),
- Activate the community 9-911 emergency response system, and
- Contact the (behavioral health) provider.
“Four behavioral health unit RNs did not fulfill their duties and responsibilities after finding the subject patient unresponsive in the room,” the report said. The nurses also did not document “accurate and complete” patient checks.
American Heart Association guidelines require “the first person to witness the need for emergency resuscitation to initiate lifesaving steps.”
Other missteps listed in the report are:
The Biloxi hospital could not provide documentation of CPR training for two of the four nurses.
A behavioral health provider was not available when the patient was admitted to the ER.
ER doctors did not document hand-off communication correctly.
Facility leaders did not report staff to state licensing boards and did not conduct an institutional disclosure to let the patient’s family know the details of the incident.
No instance of CPR or a “code blue” was documented in the patient’s treatment, which would have triggered an incident review by the hospital’s critical care committee.
During the site visit, the OIG found an expired tubing package in an unlocked emergency cart in the behavioral health unit even though the cart’s checklist verified there were no expired supplies.
Comments from the Gulf Coast Veterans Health Care System Director Bryan Matthews were included in the report. He said the hospital agrees with the report, and “We recognize opportunities for improvements in our practice and corrective actions are being implemented to address the recommendations.”
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