Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that staff delayed providing intervention and care for a patient who died following a medical emergency at a VA outpatient clinic. The OIG identified issues related to quality of care and the facility response. The OIG substantiated that a nurse delayed initiating cardiopulmonary resuscitation (CPR) after establishing the patient did not have a pulse and was not breathing, but was unable to determine if the delay led to the patient’s death. The OIG determined that failures in response to the medical emergency included ineffective emergency notification speakers to activate the emergency response, and incomplete incident documentation and review. During the inspection, the OIG identified concerns related to the quality of care provided to the patient in the days prior to and at the time of the incident that presented potential opportunities for additional assessment of the patient’s symptoms. Additional concerns included leaders’ response to the incident and staffs’ knowledge of the processes in place for advance healthcare planning with patients. The OIG found that in response to the incident, facility leaders conducted an emergency management debrief and completed an after-action review. However, facility leaders’ reviews of the incident were limited by a lack of information documented in the EHR, and decisions made based upon an unconfirmed determination of the patient’s cause of death. The OIG made five recommendations to the Facility Director related to ensuring proper outpatient clinic emergency processes including staff training, emergency notification, and documentation; ensuring compliance with CPR documentation; monitoring after-action plans for completion and compliance; consulting with the Office of General Counsel’s Regional Counsel to determine if an institutional disclosure is warranted; and evaluating and addressing staff’s understanding of advance care planning.