The Department of Veterans Affairs Office of Inspector General released its report on the incident Aug. 6. The patient died in late 2017, less than 24 hours after being admitted to the Biloxi, Miss.-based health system’s behavioral health unit.
The report found staff members failed to conduct regular 15-minute checks on the patient, as ordered by a physician. When employees found the patient unresponsive, they “did not quickly assess the patient, act with a sense of urgency, alert the care team, immediately initiate basic life support, locate the nearest automated external defibrillator, nor activate the community 9-911 emergency response system, all of which were required by policy,” the report said.
The OIG could not determine whether appropriate resuscitation efforts would’ve saved the patient.
“We recognize opportunities for improvements in our practice and corrective actions are being implemented to address the recommendations,” Bryan Matthews, director of Gulf Coast Veterans Health Care System, said in written comments included in OIG’s report.
The health system has since retrained employees on how to respond to medical emergencies, among other corrective actions.
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