Healthcare Inspection – Administrative Response to Deaths and Quality of Care Irregularities, VA North Texas Health Care System, Dallas, Texas

OIG conducted a review to determine if system leadership took appropriate administrative actions in response to reports of deaths and quality of care irregularities at the Dallas VA Medical Center (facility), part of the VA North Texas Health Care System (system). We substantiated that in 2012, a patient died after sustaining head trauma from a fall in the Radiology Department. We found system leadership had investigated the incident and disclosed the fall to the patient’s family. We identified quality of care concerns related to the timely completion and interpretation of imaging study results for the patient. We substantiated that in 2011, a patient died following baptism in a facility pool. We found the system conducted a review of the incident. However, we found system leadership did not follow up on an ethics consultation recommendation that the facility consider revising its “Do Not Resuscitate” policy to include re-addressing the status of Do Not Resuscitate orders with patients prior to any hospital procedures. We substantiated that in 2012, a facility employee died of an overdose and a patient died of a self-inflicted gunshot wound in facility restrooms. Related to the overdose death, we found system leadership did not improve employee drug testing procedures. We substantiated that in 2013, an employee was injured during transport of a patient undergoing cardiopulmonary resuscitative effort. We did not substantiate the patient being resuscitated fell from a gurney during the resuscitative efforts. We found system leadership was apprised of these events, had conducted internal reviews, and taken appropriate actions. We did not substantiate poor wound care during our site visit. Nevertheless, in 2012, system staff identified an increase in pressure ulcer prevalence and implemented several new initiatives with positive outcomes. We also found no evidence that licensed vocational nurses were administering intravenous medications. We made three recommendations.