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Healthcare Inspection – Delay in Emergency Airway Management and Concerns about Support for Nurses, VA Northern California Health Care System, Mather, CA

Report Information

Issue Date
Report Number
15-00533-440
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
At the request of Congressman Ami Bera, M.D., OIG conducted an evaluation to assess the circumstances of a patient’s death and actions taken by staff subsequently at the VA Northern California Health Care System (the facility), Mather, CA. We found that facility staff did not follow through on the patient’s request upon admission to discuss advance directives. We found no evidence of advance care planning discussion during the patient’s hospital stay. We substantiated that the patient’s wristband had the incorrect code status of Do Not Resuscitate/Do Not Intubate printed on it and that staff did not verify the wristband code status during the patient’s 9-day hospital stay. We found that the wristband had clinical warnings not pertinent to the patient’s current condition. We also found that nurses were using a duplicate copy of the wristband as a “workaround” when administering medications. We substantiated that the incorrect code status on the patient’s wristband led to a delay in life-saving intervention. We did not substantiate the allegations that medical-surgical unit staff were afraid to speak up because of the culture of bullying and retaliation on the unit. However, we concluded that an evaluation of the unit is warranted based on the unit’s All Employee Survey scores related to supervisory behaviors. We also concluded that facility leaders need to implement a plan for proactive employee support in response to traumatic events. We did not substantiate the allegation that a physician berated staff participating in the code. The facility had already started to implement corrective actions to ensure that staff verify and document patients’ code status. The facility performed an institutional disclosure of adverse events to the patient’s family and conducted a comprehensive review of the care provided for this patient in accordance with Veterans Health Administration policy. We made five recommendations.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that staff provide patients information on and assistance with completing advance directives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that corrective action plans concerning clinical warnings, including code status, on patients' wristbands are fully implemented and that managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director instruct nurse managers to conduct an inspection and ongoing monitoring of all inpatient units to ensure nurses do not make copies of wristbands for medication administration.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director conduct an evaluation of the medical-surgical unit to determine if there are issues undermining psychological safety at the work place and take action to address those issues.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develop and implement a plan for employee support following traumatic events.