Healthcare Inspection Post-Operative Paralysis Overton Brooks VA Medical Center, Shreveport, Louisiana

The VA Office of Inspector General Office of Healthcare Inspections evaluated the validity of an allegation that a patient became paralyzed after the insertion of an epidural catheter at the Overton Brooks VA Medical Center, Shreveport, LA. We did not substantiate the allegation. We concluded that the patient’s hypotension was poorly monitored and should have been treated more aggressively. We found that ICU nursing staff did not document required patient assessments. In addition, we found that the medical center’s system of reporting and evaluating adverse events needed improvement. We recommended that the Medical Center Director ensure that (1) patients in the ICU are assessed appropriately and patient care activities are consistently documented and (2) processes are in place for reporting and evaluating adverse events. Both the VISN and Medical Center Directors agreed with the findings and recommendations and provided acceptable action plans.