Report in response to affected person’s demise in 2017 particulars missteps at Biloxi VA – Veterans

(Tribune Information Service) — The demise of a affected person contained in the Biloxi VA hospital’s psychological well being unit has prompted an inspection report from the Division of Veterans Affairs’ Workplace of Inspector Normal.

Titled “Mismanagement of a Resuscitation and Different Considerations on the Gulf Coast Veterans Well being Care System,” the report issued Tuesday particulars missteps by nurses and employees associated to their actions, documentation and communication.

The demise occurred in late 2017, and the VA began an inspection Jan. four with a web site go to from Jan. 9-11, 2018.

It began with the early morning admission of a affected person, late 50s, with a historical past of IV drug abuse, the report says. Every week beforehand, the affected person had been seen on the VA for the primary time since 2006 and was assigned a major care physician.

The affected person was admitted into the ER with self-inflicted stab wounds to each thighs, made throughout an episode of alcohol and cocaine intoxication by which the affected person “freaked out.” The affected person was admitted with an preliminary analysis of despair, substance abuse, “suicidal gesture” and lacerations that required stitches.

The affected person examined constructive for cocaine and alcohol and was given a bodily and coronary heart examination with electrocardiogram.

The primary ER physician was unable to switch the affected person to a behavioral well being unit, so care transferred to a second ER physician after a shift change.

By that afternoon, the affected person was admitted to one in all two behavioral well being models (A and B) with orders of shut remark each 15 minutes. The affected person was evaluated by a nurse practitioner, then once more within the night. The affected person stated “I’m alright” appeared calm and cooperative, and took medicine, the nurse recorded.

The nurses’ log reveals the affected person was first observed to be asleep beginning at midnight. A digital camera within the hallway exterior the room confirmed a nurse checking on the affected person each 15 minutes, besides at 12:45, when a test was documented however no nurse was seen exterior the room.

The 1 a.m. test was seen on digital camera, however at 1:15 a.m., a nurse was unable to find out whether or not the affected person was respiratory, and couldn’t see the chest rising and falling.

As a substitute of instantly performing CPR or investigating additional, the nurse went again to the nurse’s station to inform the shift chief and “didn’t convey the knowledge with a way of urgency,” the report says.

Each headed again to the affected person’s room, and shift chief, or cost nurse, used a cellphone to name a nurse from the opposite unit.

The second nurse didn’t discover a pulse and noticed the affected person was not respiratory.

The primary nurse once more went again to a nurse’s station to get a stethoscope and alert the nurse assigned to the affected person, saying “we predict (the affected person) is lifeless.”

Whereas the second nurse was alone with the affected person, a time interval of solely 2 minutes, the nurse stated they carried out chest compressions and mouth-to-mouth resuscitation.

When the assigned nurse bought to the room and noticed second nurse standing on the head of the mattress, they informed the OIG they assumed CPR had already been carried out.

When the nurse from the A unit arrived to the B unit’s nursing station, the remaining nurses on the station “had been unaware of the cost nurse’s location or that an emergency was going down.”

The A unit nurse arrived to the affected person’s room the place the three different nurses had been, then left to inform the medical officer of the day (MOD), who stated “no CPR,” and relayed that to the opposite three nurses.

The MOD documented time of demise at 1:44 a.m. with out seeing the affected person. Solely a physician, not a nurse, can pronounce a demise.

An post-mortem listed the affected person’s explanation for demise as sudden cardiac demise because of cardiac arrhythmia (irregular coronary heart rhythm) and myocardial ischemia attributable to cocaine use and hypertension.

However the OIG famous that it was “unable to find out whether or not initiating full resuscitation efforts would have been profitable if employed on the time the affected person was discovered unresponsive.”

The OIG discovered the employees didn’t:

— Rapidly assess the affected person.

— Act with a way of urgency to a possible or precise emergency medical situation.

— Alert the care group of the emergency medical situation.

— Instantly provoke BLS (CPR) and find the closest AED (defibrillator).

— Activate the neighborhood 9-911 emergency response system.

— Contact the (behavioral well being) supplier.

“4 behavioral well being unit RNs didn’t fulfill their duties and tasks after discovering the topic affected person unresponsive within the room,” the report stated. The nurses additionally didn’t doc “correct and full” affected person checks.

American Coronary heart Affiliation tips require “the primary individual to witness the necessity for emergency resuscitation to provoke lifesaving steps.”

Different missteps listed within the report are:

— The Biloxi hospital couldn’t present documentation of CPR coaching for 2 of the 4 nurses.

— A behavioral well being supplier was not out there when the affected person was admitted to the ER.

— ER docs didn’t doc hand-off communication appropriately.

— Facility leaders didn’t report employees to state licensing boards and didn’t conduct an institutional disclosure to let the affected person’s household know the main points of the incident.

— No occasion of CPR or a “code blue” was documented within the affected person’s therapy, which might have triggered an incident overview by the hospital’s vital care committee.

Throughout the web site go to, the OIG discovered an expired tubing package deal in an unlocked emergency cart within the behavioral well being unit though the cart’s guidelines verified there have been no expired provides.

Feedback from the Gulf Coast Veterans Well being Care System Director Bryan Matthews had been included within the report. He stated the hospital agrees with the report, and “We acknowledge alternatives for enhancements in our observe and corrective actions are being carried out to handle the suggestions.”

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