A report from the Department of Veterans Affairs Inspector General’s Office is calling for major improvements at Buffalo's VA Medical Center.
This comes after medical personal at the facility failed to resuscitate a patient suffering cardiac arrest in late 2016. The report says a registered nurse and respiratory therapist “acted outside their scopes of practice and violated Veterans Health Administration and facility policy when the announced that the patient was dead.”
New York Senator Kirsten Gillibrand says we’re not providing the best care possible for our veterans.
"We need much more accountability and we need clarity from the Department of Veterans Affairs," said Gillibrand. "I've had concerns with the VA over the last year on a number of issues. I will ask for a hearing on this specifically along with some of the other issues we have heard from throughout the state where the VA isn't supporting our veterans the way they are supposed to be."
A report last year showed 526 patients of the Buffalo VAMC may have been put at risk of infection due to improperly cleaned medical scopes. Gillibrand sent a letter today to Interim Healthcare Systems Director Michael Shwartz asking him to implement management the inspector general recommended changes immediately.
Below are the ten recommendations from the VA Inspector General's Investigation:
- We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
- We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
- We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
- We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
- We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
- We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
- We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
- We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
- We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
- We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.
The Buffalo VA Medical Center released this statement regarding the matter:
“We appreciate the Office of Inspector General’s oversight which is precisely why VA Western New York Healthcare System leadership self-reported this incident to the OIG.
Secretary 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 tax payers expect, and that's exactly what we will do in this case.
In the meantime, VAWNYHS 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.
We continue to work with veterans, community stakeholders and local and national VA leaders in order to complete all of the inspector general's recommendations."
