Mismanagement of a Patient at the Tomah VA Medical Center in Wisconsin

The VA Office of Inspector General (OIG) reviewed allegations referred by Congressman Ron Kind regarding the care of a patient at the Tomah VA Medical Center (facility) who subsequently died from a presumed anoxic brain injury. The OIG did not substantiate staff over-sedated the patient. The OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram prior to haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death. The OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active. Facility leaders and staff reported lack of knowledge about the failed oxygen delivery. The OIG did not substantiate that staff failed to document non VA emergency medical services. Nursing staff did not complete all required alcohol withdrawal assessments. A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected. The OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required. Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update. The OIG made 10 recommendations to the Facility Director related to education regarding alcohol withdrawal, cardiac risks, review to determine causes of failed oxygen delivery, root causes and performance deficiencies, workgroup outcome, alcohol withdrawal assessment protocol adherence, restraint management and training, compliance with admission criteria, emergency detention, and institutional disclosure.