HAMPTON, Va. (WAVY) — An investigation into a patient’s death at the Hampton VA Medical Center found nursing staff failed to properly check the patient when his health was deteriorating and failed to document changes to his condition.
The Department of Veterans Affairs Office of Inspector General released the report Wednesday. To view the full report click, here.
The report centers around a quadriplegic and a long-time patient at the facility’s Spinal Cord Injury (SCI) Center that died last year.
The report says the patient required much assistance. According to the patient’s electronic health records (EHR), the patient started to have back and neck pains in Spring 2013. He told staff he wanted to stay in bed. Later that morning, a nurse gave the patient his morning medications and documented that he was awake and alert.
Close to noon, a pharmacist and his doctor visited the patient and noted he was alert. The physician adjusted the patient’s medications and told staff to monitor him. Three hours later, the day shift nurse recorded in the patient’s EHR that during his noon medication administration the patient was sleeping, but easily awaken.
After a shift change in the afternoon, a nurse found the patient breathing, but unresponsive. She alerted the Rapid Response Team and within 5 minutes the team began treating him and monitoring his heart rate and blood pressure. The team could not wake up the patient. He ended up in the Intensive Care Unit.
Two days later, the patient was not doing well and remained unresponsive. On the following day, the patient recorded a fever of 101 degrees and had a “multi-drug resistant organism infection.” On day 4, medical staff met with the patient’s family to talk about his condition and told them he could not survive without ventilation. He had little brain function.
The patient died on day 5 after his ventilation was removed. His cause of death was listed as aspiration Pneumonia with anoxic brain injury.
The report found that the nursing staff did not perform timely routine checks in accordance to the facility’s policy. The nursing staff was to make checks every 30 minutes and assess the patient’s condition. The report states the nurses had “an inconsistent understanding of the facility’s policy regarding the frequency of rounds.” It found some reported a standard of every 20 minutes, while others reported a standard of every three hours.
The report also found that the staff did not document the patient’s change on condition in the EHR.
Investigators say the staff also failed to take appropriate action when non-nursing staff informed them that something was wrong with the patient.
Investigators say the nurses never fully understood what was expected of them, but investigators say they “could not determine that a delay in nursing response was the patient’s cause of death,” due partly to lack of evidence.
The Office of Inspector General recommended changes to the facility’s education and training polices. It recommended the Hampton VA Medical Center review its patient check policies and medical record documentation polices and train and educate the staff on the issue.
Following the release of the report, the VA’s Director Michael Dunfee issued a response to the report. He says the center concurs with the recommendations and says that they, “acknowledge that further education and training is required to clarify expectations for the rounding process, to include the timing of rounds and expectations for the staff to document when there is a significant change in the patient’s condition, diagnosis or status. ”
He says further training and education to clarify its expectations for patients’ health started on Aug. 1.