Healthcare Inspection Allegations Concerning Respiratory Therapy and Nursing VA Medical Center Memphis, Tennessee

The VA Office of Inspector General, Office of Healthcare Inspections, conducted an evaluation in response to two anonymous complaints regarding respiratory therapy (RT) and nurse staffing issues at the VA Medical Center (the medical center) in Memphis, Tennessee. The purpose of the review was to determine whether the allegations had merit. We confirmed that two RTs and a surgery resident were unable to intubate a patient; however, we did not substantiate that this contributed to the patient’s death. Medical record documentation clearly reflects that the patient was ventilated between intubation attempts, and RT competency files reflected appropriate certification and competence in airway management. We did not substantiate that ambulatory surgery unit nurses were assigned to the gastroenterology (GI) recovery unit, leaving the ambulatory surgery unit unsafely staffed. We also did not substantiate that an ambulatory surgery unit nurse worked alone on the GI recovery unit. The units were physically located in the same space and nurses could easily assist each other if needed. We noted that actions were being taken to enhance RT and nurse staffing in both areas. The VISN and medical center Directors agreed with our report. We made no recommendations.