Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess the quality of care provided during a patient’s hospitalization, which ended with the patient’s death at the Lt. Col. Luke Weathers, Jr. VA Medical Center (facility) in Memphis, Tennessee. The OIG also evaluated facility leaders’ response to the patient’s care.

A telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a blue alert, which may have affected the patient’s outcome. A charge nurse’s failure to assign a nurse to care for the patient or provide accurate nursing assignments to the telemetry technician may have also contributed to the delay. Additionally, an intensive care unit fellow did not document a response to a critical care consult and did not recall the patient, rendering the OIG unable to determine the clinical decision-making rationale.

Facility leaders’ factfinding and root cause analysis reviews of the patient’s care were not thorough, which hindered identification of systemic and causal factors. Contributing factors included a nursing leader who did not issue an authorization letter to provide the factfinding investigator guidance on the focus of the review, and the root cause analysis team who did not interview some staff directly involved with the patient event, as required.

The OIG made five recommendations to the Facility Director related to compliance with the cardiac telemetry monitoring policy, making and communicating nursing assignments, documenting critical care consults, conducting factfindings and root cause analyses, and consideration of another root cause analysis.