OIG report on Biloxi VA patient care

Four behavioral health unit RNs at the Gulf Coast Veterans Health Care System facility in Biloxi, Miss., did not fulfill their duties and responsibilities after finding an unresponsive patient in 2017 according to a VA inspector general report. The RNs did not act with a sense of urgency to perform timely CPR, locate and bring an Automated External Defibrillator (AED) to the patient’s room, or activate an emergency response system as required by policy. The facility could not provide the IG team with basic life support (BLS) certification for two of the four nurses. Based on available facts, the OIG was unable to determine whether initiating full resuscitation would have been successful. The unit (25-A) nurse called the medical officer of the day to “pronounce a patient” deceased. The MOD documented a nurse had examined and deemed the patient dead. VHA policy states only medical doctors can pronounce a patient death while under the care of the VA. The behavioral health unit nursing staff did not document accurate and complete 15-minute patient observation checks. A behavioral health assessment treatment provider was not available when the patient presented to the emergency department. Emergency department providers did not document hand-off communication or with the behavioral health admission provider. The OIG reviewed facility leaders’ response to the event and found facility leaders removed the involved staff from patient care and completed a fact-finding review and Root Cause Analysis. Facility leaders did not pursue reporting staff to the state licensing boards and did not conduct an institutional disclosure. During the site visit in January 2018, the OIG found an expired tubing package on the behavioral health unit’s emergency cart although staff had signed the cart’s checklist verifying that there were no expired supplies. The designated facility committee did not review the resuscitation as the unit RNs did not complete the required cardiopulmonary arrest record. (Source: VA Inspector General 08/06/19)