Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona

Report Information

Issue Date
Report Number
23-02958-203
VISN
State
Arizona
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.

The OIG determined the patient experienced a delay in receiving BLS. The OIG learned of deficiencies related to the initiation of emergency medical care, including (1) conflicting facility policies that were inconsistent with Veterans Health Administration (VHA) requirements, (2) lack of layperson cardiopulmonary resuscitation (CPR) training, and (3) lack of an automatic external defibrillator (AED).

Quality of care concerns were also identified, which included a discrepancy between the documented plan for a wearable cardioverter defibrillator (WCD) and the absence of an order for the device, and a failure to assess vital signs at an appointment preceding the medical emergency. The OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.

Facility leaders’ lack of response upon awareness of the event did not align with high reliability organization (HRO) principles and I CARE values. The OIG identified the patient safety manager did not facilitate a thorough investigation of the related patient safety report, which resulted in an inaccurate harm assessment. Additionally, the patient safety manager and Facility Director failed to ensure a timely review of the report and investigation.

The OIG made 10 recommendations to the Facility Director related to congruence of facility policies and their alignment with VHA Directives, layperson CPR training, placement of AEDs at the facility, outpatient clinic compliance with vital signs completion, complaint review processes, communicating in alignment with HRO and I CARE values, training on patient safety reporting, and investigation and closure of patient safety reports.
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2025

The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2025

The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2025

The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.