Report Summary

The VA Office of Inspector General (OIG) assessed an allegation at the Michael E. DeBakey VA Medical Center (facility) that community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).

The OIG substantiated that a CLC nurse delayed initiation of resuscitation efforts for Patient A. The OIG found that the CLC nurse identified Patient’s A’s code status as DNR after checking a report sheet and seeing a DNR armband. However, Patient A was a full code status, as reflected in the EHR. The nurse did not review the EHR, causing delayed resuscitation efforts.

The OIG substantiated that facility inpatient nursing staff attempted to resuscitate Patient B who had a DNR order. Inpatient nursing staff relied on the absence of a DNR armband to indicate Patient B’s code status and relayed the incorrect code status to the code blue team during the patient’s cardiac arrest. The code blue team performed resuscitative efforts until a medical resident reviewed the EHR and identified Patient B’s status as DNR.

The OIG identified concerns related to the use of DNR armbands and the suspension of DNR orders in the operating room.

The OIG made one recommendation to the Under Secretary for Health regarding reviewing DNR processes and five recommendations to the Facility Director related to staff’s EHR verification of life-sustaining treatment orders and patients’ code statuses, evaluation of corrective actions from management reviews, location of life-sustaining treatment orders within the EHR, modifications to patients’ life-sustaining treatment orders during surgical procedures, and staff’s review of patients’ code statuses upon patients’ return to facility units from surgical procedures.