A veteran who died under the care of the Veterans Affairs (VA) center in Wyoming had faced a delay in basic life support and a veteran who died in a suicide at a center in Arizona had received inadequate care, according to the agency’s watchdog.
The patient in Arizona attended an appointment at the center, and a family member attended to provide a ride home, according to the report. The patient became unresponsive while still on the VA grounds, and the family member drove the car to the front entrance and entered the lobby for help.
The employee at the front desk dialed 911 and did not initiate a rapid response. The patient received basic life support from the Phoenix Fire Department about 11 minutes later. Two days later, the patient died.
“Clinical leaders told the OIG that a rapid response would have prevented the patient from experiencing a delay in receiving basic life support,” and the OIG substantiated that the patient experienced that delay, according to the report.
“The OIG also identified deficiencies in the initiation of the patient’s emergency medical care, the quality of the patient’s care prior to the medical emergency, and completion of comprehensive quality reviews,” the reports stated.
In addition, facility policies were inconsistent with Veterans Health Administration requirements, and the report found a lack of cardiopulmonary resuscitation training for laypersons and no automatic external defibrillator at the facility.
“VA medical facilities should never allow a patient to suffer on their premises without alerting staff to provide emergency care when and where it is needed,” U.S. Sen. Jerry Moran (R-Kan.), the ranking member of the Senate Committee on Veterans’ Affairs, wrote in an email to The Epoch Times.
“The OIG continues to report on inconsistent rapid response policies across the VA, and the department needs to address this issue system-wide.”
In the case of the inpatient who died by hanging at the Sheridan VA Medical Center, the report found that staff did not follow policy by failing to remove the patient’s belongings.
A nurse also failed to conduct a warm handoff—which is required as part of the comprehensive suicide risk evaluation (CSRE)—and a psychiatrist did not complete the required CSRE or reassess the patient on the third day before changing the patient’s observation status, the OIG found.
The veteran was found dead on his fourth day in the VA and took his own life with a necklace that the VA staff failed to remove.
“I am concerned about VA’s overall suicide prevention strategy and the department’s mental health workforce,” Mr. Moran said. “VA must make certain that all of the department’s mental health clinicians and staff are trained in delivering evidence-based therapy, are adhering to screening guidelines, and are appropriately transferring care for veterans at risk of suicide.
In response to the OIG report on the Phoenix incident and its recommendations, VA Desert Pacific Healthcare Network Director Steven Braverman wrote in a letter to the watchdog, “Based on the thorough review of the report by VISN [Veterans Integrated Services Network] 22 Leadership, I concur with the recommendations and submitted action plans of Phoenix VA Health Care System.”
In response to the watchdog’s report on the Wyoming veteran, VA Rocky Mountain Network Director Sunaina Kumar-Giebel wrote: “We deeply regret the circumstances that led to this veteran’s death. There is nothing more important to us in VISN 19 than ensuring veterans receive quality care and that it is provided by knowledgeable, skilled staff.”
Ms. Kumar-Giebel indicated that the network thoroughly reviewed the report and concurred with the OIG’s recommendations. The VISN also submitted action plans for the Sheridan VA Health Care System.
“These recommendations will be used to strengthen our processes and improve the care that is provided to our veterans,” Ms. Kumar-Giebel wrote.
