Deficiencies in Care and Excessive Use of Restraints for a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to the care provided to a patient who died at the Charlie Norwood VA Medical Center (facility) and an allegation that the Facility Director failed to ensure adequate psychiatric provider coverage. The OIG did not substantiate that the patient died due to overmedication, because the cause of death was bilateral pulmonary thromboemboli with prolonged restraint and “noncontributory” toxicology findings. However, the OIG identified deficiencies during the patient’s care that likely contributed to the patient’s death. Staff improperly ordered and initiated medical-surgical restraint for the patient. Given that the patient was restrained for approximately 71 hours, the staff’s failure to effectively address the patient’s deep vein thrombosis prophylaxis needs contributed to the patient’s death. Staff’s failure to address the patient’s nicotine dependence may have contributed to the worsening of the patient’s agitation that led to restraint usage. Facility leaders and staff failed to comply with Georgia State law involuntary commitment process requirements. The OIG substantiated that the lack of mental health provider involvement likely contributed to the patient’s death, and the patient endured an unnecessary four-hour ambulance trip in restraints that likely contributed to the development of pulmonary thromboemboli. The OIG substantiated that the facility’s Downtown Division lacked adequate psychiatric providers to manage mental health emergencies and that leaders failed to ensure a psychiatrist was included on their code gray team. Also, nurse practitioners had been cancelling outpatient appointments so they could respond to Downtown Division mental health consult requests. The OIG concluded that the Disruptive Behavior Committee failed to provide input that may have reduced the patient’s risk of violence throughout the patient’s care and may have contributed to the mismanagement of the patient’s mental health treatment needs. The OIG made 18 recommendations.