WASHINGTON — Medical personnel at the Buffalo VA Medical Center failed to try to resuscitate a patient suffering cardiac arrest in late 2016, pronouncing him dead even though they should have tried to save his life, the Department of Veterans Affairs Inspector General's Office said in a devastating report that recommended sweeping improvements in the facility's practices during life-or-death emergencies.
A registered nurse and respiratory therapist "acted outside their scopes of practice and violated Veterans Health Administration and facility policy when they announced that the patient was dead, which influenced others not to take appropriate action," said the report, which was published Monday and obtained by The Buffalo News Tuesday.
The report – which comes less than a year after revelations that 526 patients at the VA hospital could have been put at risk of infection due to improperly cleaned medical scopes – outraged Sen. Kirsten E. Gillibrand, a New York Democrat who serves on the Armed Services Committee.
"This report has confirmed my fears of a pattern of sub-par treatment of veterans in Western New York at the Buffalo VA," Gillibrand said. "Incidents like this should never happen, and we need to take steps to provide oversight and accountability to ensure this never happens again.”
The report is vague on some details, never naming the patient, who subsequently died, or exactly when the incident occurred.
But the report does say that hospital management contacted the inspector general's Criminal Inspection Division early last year to report the death of a patient "who did not receive immediate life-sustaining treatment after staff determined the patient was unresponsive."
The registered nurse did not want to attempt cardiopulmonary resuscitation because the patient was frail, fearing CPR could have crushed his chest, the inspector general's report said.
Another registered nurse failed to monitor the patient's heart rhythms. That nurse also left unattended the desk where she was charged with monitoring the vital signs of other patients, "thereby temporarily placing other monitored patients at risk," the report said.
None of those other 11 patients suffered any problems, though, because of that nurse abandoning the monitoring station, the report said.
Meantime, a licensed practical nurse failed to activate a "Code Blue" response indicating that the patient suffering cardiac arrest was having a medical emergency. That nurse also failed to administer CPR on the gravely ill patient.
Investigators also found that staff at the hospital reacted poorly after the patient died.
Staffers should have, but didn't, preserve the late patient's cardiac monitoring data.
Hospital leaders should have, but didn't, immediately remove the staffers involved in the incident from patient care duties pending the completion of an investigation.
Top hospital officials failed to quickly pull together an Administrative Investigation Board to review the incident.
They also didn't do a "Root Cause Analysis" to try to identify possible systemic problems that could have led to the botched handling of the veteran's cardiac arrest.
And on top of all that, hospital staff failed to promptly and properly report the potential lapses in quality care to the patient's family, investigators added.
The incident prompted Dr. John D. Daigh Jr., assistant VA inspector general for healthcare inspections, to issue a series of recommendations to the Buffalo VA's facility director. Daigh recommended that the hospital chief should:
- Review the incident and confer with the Office of Human Resources and the VA general counsel to determine if actions should be taken in response to it.
- Ensure that hospital staff take part in mock drills to prepare them to take appropriate actions when such health emergencies occur.
- Conduct a review to see if there are "issues undermining teamwork" at the facility.
- Guarantee that staff assess patients both before and after breathing treatments and document the patients' response.
- Review the staff's communications with the late veteran's family and make amends if that's appropriate.
In a memo at the end of the report, the interim head of the Buffalo VA facility concurred with the inspector general's recommendations.
"Corrective action plans have been established with planned completion dates," said Paul S. Crews, who until recently served as interim health care system director for the VA Western New York Healthcare System.
A spokeswoman for the hospital, Evangeline Conley, said officials there appreciate the inspector general's work – which is why they reported the incident to the inspector general.
VA Secretary David Shulkin "has made it clear that he will hold employees accountable when the facts demonstrate that they have failed to live up to the high standards veterans and taxpayers expect, and that’s exactly what we will do in this case," Conley said. "In the meantime, (the hospital) wants to assure veterans and their family members that our facility is a safe environment and our employees remain dedicated to providing quality health care."
Gillibrand said she planned to ask the Senate Veterans Affairs Committee to hold a hearing on the incident.
And on Tuesday, Gillibrand sent a letter to Michael J. Swartz, who succeeded Crews, asking that he immediately implement the 10 management changes that the inspector general recommended.
"Some of these items seem painfully basic in the proper administration of a medical facility, but can make the difference between life and death for patients," Gillibrand wrote. "No veteran should have to wonder whether his or her local VA facility is properly training its staff in the management of life or death emergency scenarios when a patient’s health suddenly escalates."