VA OIG report reveals Buffalo VA staff failed to try to resuscitate dying patient

The Veterans Affairs Office of Inspector General evaluated the circumstances surrounding a patient's death in 2016 at the Buffalo (N.Y.) VA Medical Center and found the facility's nurses failed to try to resuscitate the patient, who was suffering cardiac arrest, according to a VA OIG report published March 12.

The medical personnel pronounced the patient dead even though they should have attempted resuscitation, the report said. The report did not name the patient, who died after the incident, or when the incident occurred.

A registered nurse and respiratory therapist at the facility "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," according to the report.

The registered nurse did not want to attempt CPR out of fear that it would have crushed the already frail patient's chest, according to the report. A different registered nurse failed to monitor the patient's heart rhythms and also left the desk where she monitored other patients' vital signs unattended, "thereby temporarily placing other monitored patients at risk," the report said.

Hospital staff also failed to properly report the potential lapses in quality care to the patient's family in a timely manner.

Additionally, the facility's leaders did not immediately remove the staffers involved in the incident from patient care duties pending the investigation's completion.  

In response to the incident, John Daigh Jr., MD, assistant VA inspector general for healthcare inspections, issued a series of recommendations to the Buffalo VA's facility director, such as ensuring hospital staff take part in mock drills to prepare for health emergencies, conducting a review to see if there are "issues undermining teamwork" at the facility and reviewing staff communications with the late veteran's family.

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