Facility Leaders’ Failures in Communications, Construction Oversight, Emergency Preparedness, and Response to an Oxygen Disruption at the West Haven VA Medical Center in Connecticut

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a disruption to the facility’s oxygen line, patient safety concerns, and facility leaders’ response at the West Haven VA Medical Center (facility) in Connecticut. A construction company unintentionally cut the facility’s oxygen line, causing an oxygen disruption. While the facility relied on portable oxygen tanks and concentrators, a patient experienced an adverse event, and ultimately died after a period of inadequate oxygen supply. The OIG found that a lack of accessible equipment, education, and training contributed to the patient’s adverse event. The OIG was unable to determine whether this led to the patient’s unresponsiveness or death. No other patients experienced adverse clinical outcomes. The OIG determined that after the oxygen disruption, facility staff transitioned patients to portable oxygen tanks and concentrators, while facility leaders implemented incident command processes. However, the OIG found a lack of communication between facility leaders, staff, and patients when deciding to continue providing care to patients requiring oxygen at the facility. Prior to the oxygen disruption, facility staff did not complete the required risk assessment involving patient safety staff, and the contractor’s work was not adequately observed. Additionally, there was a lack of periodic drills for utility emergencies and a lack of knowledge of emergency procedures. The OIG found deficiencies with administrative and quality reviews that included • failure to ensure timely patient safety reports and root cause analyses, • inhibited peer review processes due to clinical staff’s inadequate documentation, • failure to clinically disclose the incident regarding the patient, • concerns with the validity of a fact-finding review, and • preparation for OIG interviews with incomplete and inaccurate information. The OIG made 12 recommendations related to communication, emergency preparedness, construction risk assessments and oversight, administrative and quality reviews, and preparation for OIG interviews.