Healthcare Inspection – Mismanagement of Resuscitation and Other Concerns at the Buffalo VA Medical Center, Buffalo, New York

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the circumstances of a patient’s death involving alleged mismanagement of the patient’s resuscitation (Event) at the Buffalo VA Medical Center (Facility), Buffalo, New York, and actions taken by Facility leaders subsequent to the death. The Facility Director contacted the OIG to report a registered nurse (RN 1) found the patient unresponsive and did not “call a code” because he/she feared cardiopulmonary resuscitation (CPR) would traumatize the patient’s body. The OIG substantiated RN 1 did not “call a code” after finding the full-code patient unresponsive. The OIG determined • RN 1 and a respiratory therapist (RT) acted outside their scopes of practice and violated policy when they announced the patient was dead, which influenced others not to take action; • A telemetry RN (RN 2) failed to call for assistance and abandoned the telemetry desk during the Event; • A licensed practical nurse failed to call for assistance and initiate CPR; • Telemetry monitoring failures contributed to the delayed response to the Event; • RN 1 failed to document the patient’s lung assessment and the RT failed to assess the patient’s respiratory status, before and after a scheduled respiratory treatment; and • The Facility’s Performance Manager’s conversation with the patient’s family could have been misunderstood. The OIG identified administrative concerns related to Facility leaders’ responses to the Event. Specifically, Facility leaders did not immediately remove involved staff from direct patient care, conduct a timely Administrative Investigation Board and Root Cause Analysis, submit an Issue Brief to the Veterans Integrated Service Network, and pursue notifying the patient’s family or personal representative. The OIG found Facility staff failed to preserve the patient’s telemetry data. The Facility did not have a policy and Veterans Health Administration has not provided guidance about preservation of evidence after an adverse event. The OIG made 10 recommendations.