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VA staff who didn't try to resuscitate patient left their jobs after scathing report

WASHINGTON — Two Buffalo Veterans Affairs Medical Center employees left their jobs after they were implicated in the botched decision not to try to revive a patient suffering cardiac arrest, a spokeswoman for the facility said Wednesday.

A report from the Department of Affairs Inspector General released earlier this week said staffers at the hospital should have tried to resuscitate that patient when he fell gravely ill in late 2016. The Inspector General also criticized the hospital for not immediately removing the staffers from patient-care duties while it investigated the incident.

But Evangeline Conley, spokeswoman for the hospital, said the employees were disciplined.

"In response to this report, two employees have been proposed for removal and both no longer work for VA," Conley said. "Another employee has received the appropriate level of discipline, and more disciplinary actions are possible."

Conley declined to provide further details, such as the titles of those disciplined, for privacy reasons.

The report, which the center received in November and which was released to The Buffalo News this week, offers a scathing review of the actions of several Buffalo VA employees at a time of crisis for the patient, who died after failing to get the proper treatment.

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," the report said.

The registered nurse did not want to perform cardiopulmonary resuscitation out of fear that the patient was so frail that the procedure could crush his chest, the report said.

Another registered nurse should have, but didn't, monitor the patient's heart rhythms. That nurse also abandoned the desk where she was supposed to monitor the vital signs of other patients, "thereby temporarily placing other monitored patients at risk," the report said.

Investigators: Buffalo VA staff failed to try to resuscitate patient

The incident prompted the Inspector General's office to issue several recommendations.

The hospital's top officer 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, set up mock drills to make sure employees react appropriately to health emergencies, and conduct a review to identify any "issues undermining teamwork," the report said.

The Buffalo VA hospital said in the report that it would adopt the recommendations, and Conley, the hospital spokeswoman, stressed that the facility is taking the report seriously.

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," she said.

The report enraged members of Congress who serve the Buffalo area.

Sen. Kirsten E. Gillibrand, a New York Democrat who sits on the Armed Services Committee, called on the Senate Veterans Affairs Committee to hold a hearing on the matter.

“Providing the highest standard of care for our veterans is a solemn promise that should never be broken," Gillibrand said.

Rep. Brian Higgins, a Buffalo Democrat, said he plans to write to Shulkin about the incident. He also noted that the problems at the Buffalo VA are by no means unique.

"These problems are, unfortunately, defining the entire VA system in Buffalo and nationally," he said.

Part of the problem, Higgins said, is that VA hospitals are overcrowded and outdated. He suggested upgrading them, using funds that could be saved if the United States pulled its forces out of Afghanistan and Iraq.

Rep. Tom Reed, a Corning Republican, called the Inspector General's report "very concerning." But he said he was heartened that Michael J. Swartz recently took over as interim health care system director at the Buffalo VA facility.

Reed came to know Swartz when he ran the VA facilities in Bath and Canandaigua, and called Swartz after seeing the Inspector General's report earlier this week.

"He's already taking steps to improve the system," Reed said. "I know Mike, I know his commitment to veterans. I'm confident he will do what's necessary."

Rep. Chris Collins, in a letter to Shulkin, also praised Swartz.

"While he is working to change the culture at the facility and ensure that our service men and women are treated properly, there is a systemic problem across the entire VA healthcare system," said Collins, who asked Shulkin's office to oversee the implementation of the Inspector General's recommendations in Buffalo and at other VA facilities around the country.


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