Facility Leaders’ Failures in Communications, Construction Oversight, Emergency Preparedness, and Response to an Oxygen Disruption at the West Haven VA Medical Center in Connecticut

Report Information

Issue Date
Report Number
22-01696-160
VISN
1
State
Connecticut
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a disruption to the facility’s oxygen line, patient safety concerns, and facility leaders’ response at the West Haven VA Medical Center (facility) in Connecticut. A construction company unintentionally cut the facility’s oxygen line, causing an oxygen disruption. While the facility relied on portable oxygen tanks and concentrators, a patient experienced an adverse event, and ultimately died after a period of inadequate oxygen supply. The OIG found that a lack of accessible equipment, education, and training contributed to the patient’s adverse event. The OIG was unable to determine whether this led to the patient’s unresponsiveness or death. No other patients experienced adverse clinical outcomes. The OIG determined that after the oxygen disruption, facility staff transitioned patients to portable oxygen tanks and concentrators, while facility leaders implemented incident command processes. However, the OIG found a lack of communication between facility leaders, staff, and patients when deciding to continue providing care to patients requiring oxygen at the facility. Prior to the oxygen disruption, facility staff did not complete the required risk assessment involving patient safety staff, and the contractor’s work was not adequately observed. Additionally, there was a lack of periodic drills for utility emergencies and a lack of knowledge of emergency procedures. The OIG found deficiencies with administrative and quality reviews that included • failure to ensure timely patient safety reports and root cause analyses, • inhibited peer review processes due to clinical staff’s inadequate documentation, • failure to clinically disclose the incident regarding the patient, • concerns with the validity of a fact-finding review, and • preparation for OIG interviews with incomplete and inaccurate information. The OIG made 12 recommendations related to communication, emergency preparedness, construction risk assessments and oversight, administrative and quality reviews, and preparation for OIG interviews.

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)

The West Haven VA Medical Center Director ensures communication with patients, families, and staff throughout emergency operations according to the Veterans Health Administration’s Emergency Management Program Guidebook.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director confirms that medical, nursing, and respiratory therapy staff have the equipment, education, and training to prepare for emergency oxygen procedures.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures completion of pre-construction risk assessments.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures patient safety staff participate in facility Construction Safety Committee meetings and activities.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director evaluates the need for increased oversight of contracted construction companies during high-risk or potential high-risk situations such as construction around underground utilities.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures annual drills and training to address utility emergencies are completed.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director confirms that joint patient safety reports are entered for adverse events and close calls and root cause analyses are chartered for high-risk events or potential high-risk events not related to falls, medications, and missing patients.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures clinical staff document each event of a patient’s care into the health record.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures that the patient’s episodes of care are reviewed to determine whether a clinical disclosure is needed in accordance with Veterans Health Administration requirements and takes action accordingly.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures that staff who are designated as a fact finder for a fact-finding investigation receive the needed training and do not have a conflict of interest.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director determines whether administrative action should be taken with respect to the conduct and performance of the chief of respiratory care.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews the content, accuracy, and intent of the Situation, Background, Assessment, Recommendation document and takes administrative action as warranted.