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Federal report slams care of local VA patient who died

Published: May. 17, 2022 at 3:51 PM EDT|Updated: May. 17, 2022 at 6:46 PM EDT
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AUGUSTA, Ga. (WRDW/WAGT) - An inquiry found serious problems with the Charlie Norwood Veterans Affairs Medical Center’s care of a patient who ultimately died.

The findings are outlined in a report from the Department of Veterans Affairs Office of Inspector General that details the patient’s care as well as concerns about that care.

The patient underwent minimally invasive urologic surgery at the facility in fall 2020 and died 13 days later in the intensive care unit while suffering alcohol withdrawal and declining health.

The office said it was concerned about the quality of care in the months before surgery. The provider’s failures most likely contributed to the patient’s poor health going into the preoperative phase, the report says.

The report’s findings include:

  • Before surgery, the primary care staff failed to provide sufficient care coordination and treatment.
  • A provider failed to address the patient’s abnormal chest images and poor nutrition and failed to communicate test results to the patient as required.
  • A primary care nurse failed to respond to the patient’s request for assistance two days before surgery.
  • A barium swallow test was not scheduled.
  • The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health.
  • During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.

Full Report:

The office recommended that the Veterans Integrated Service Network director review the provider’s care of the patient.

In addition, recommendations to the facility director focused on access to same-day care, communication of test results and treatment plans, assigned surrogates, preoperative care, medical-surgical nurses’ patient care, staff education, nursing competencies for alcohol withdrawal assessments and treatment, medical-surgical unit nurses’ quality control oversight, and alcohol withdrawal treatment protocol.

All of those recommendations are open as of Tuesday.

What led up to the investigation?

In the year before surgery, the patient had multiple abnormal chest images and was prescribed four cycles of antibiotics. Despite two patient requests and a recommendation from a radiologist, the provider failed to consult a pulmonologist, the office found.

The provider stated that the treatment plan was to repeat CT scans, order a barium swallow and a bone density test, and prescribe cough syrup and antibiotics. The provider signed an order for a barium swallow test four months before surgery, but the test was not scheduled or completed. The facility staff was unable why. The provider did not order a bone density test.

The office found the provider failed to adequately address the patient’s poor nutritional status. The provider failed to document the patient’s weight loss but addressed blood test abnormalities by repeating blood tests, offering dietary suggestions, instructing the patient to supplement with a sports drink, and suggesting the patient go to the emergency department if symptoms worsened.

Three weeks before surgery, the provider received the results of the patient’s third abnormal blood test. The provider failed to communicate the results to the patient within seven days as required by policy. The provider mailed the results to the patient 13 days later, but failed to highlight the abnormalities or provide a plan of care. Facility leaders reported no concerns with the practice, and the provider passed ongoing professional practice evaluations through May 2020.

The office said that two days before surgery, a nurse responded to a message from the patient, who complained of being weak and not able to keep “anything down.” The nurse did not alert a primary care provider, call the patient, schedule a same-day appointment or note the provider’s instructions to have the patient go to the emergency department if symptomatic. The nurse could not recall why these deficiencies occurred.

After the surgery, the office determined none of the patient’s five post-surgical nurses consistently assessed alcohol withdrawal symptoms or administered medications according to protocol and physician orders. The office found inadequate training or protocols to ensure safe and effective alcohol withdrawal nursing care in the medical-surgical unit.

The office also found the facility’s protocol made it possible for alcohol withdrawal treatment to end only 16 hours into a patient’s hospital admission, even though onset may begin one to five days after cessation or reduction in alcohol use.

The report also found issues with the placement of the patient in a raised-feet “Trendelburg” position, citing inadequate explanations of who asked that the patient be put in that position or for how long.

In addition, the medical-surgical unit nurse manager did not conduct periodic chart reviews of documentation to monitor the quality of nursing care, the report says.

The report gives a list of recommendations to the VA to prevent something like this from happening again. They suggest setting a standard to ensure care is of acceptable quality, getting training for alcohol withdrawal treatment, and making sure they care and take action for a patient is warranted.

Norwood’s response

“We offer our deepest condolences to the family and friends of the Veteran at the center of this report,” the hospital said in a statement Tuesday.

The hospital said it has begun implementing each of the report’s recommendations and expects to complete the last one in July 2022.

The hospital said it:

  • Thoroughly reviewed same-day access. As a result, a same-day clinic was reopened in December at the downtown campus. In addition, teams continue to offer veterans several options to for same-day access for physical and mental health concerns.
  • Has reviewed and revised the alcohol detoxification protocol, related computerized orders, and medical record notes “to ensure congruency between them and to ensure alignment with evidence-based best practices.”
  • Has undergone a comprehensive evaluation of its education department, conducted by an executive staff member from a different VA facility. As a result, it has “instituted an action plan to implement a robust orientation and increased practice oversight for its clinicians.” The hospital also added “evidence-based” practice nurses and “pathway to excellence” coordinators to ensure ongoing evaluation of the quality of nursing and clinical care.
  • Continues to implement new processes and the necessary quality reviews to ensure veterans get the highest quality care.

I-TEAM Update

This is just the latest in a series of failures our I-Team has been investigating when it comes to local military families.

A few weeks ago, our I-Team was in Washington D.C. when the Senate Permanent Subcommittee on Investigations held a hearing about military housing at Fort Gordon.

For more than a decade, we’ve exposed problems on post. Some were so serious it made local families sick. Senator John Ossoff and his team cited our reporting in their work that has prompted the Army to launch its own investigation at Fort Gordon. We’re working on an update and will have much more coming up Thursday

During another hearing on Capitol Hill, Army leaders acknowledged sexual harassment is ‘rampant.’ So rampant, leaders have moved prevention training to a soldier’s first 72 hours instead of during week two. They say top brass will continue to meet monthly to work on ways to make the service environment better for everyone.

Previous investigations at Charlie Norwood

  • July 2019: The office identified concerns with Charlie Norwood staff not feeling supported by leaders, an inefficient hiring process, and inadequate communication of policies, among other administrative issues. The office made 27 recommendations, two of which remained open as of Sept. 2, 2021.
  • May 2020: The office outlined non-compliant practices and other issues that contributed to adverse patient events and clinical outcomes at Charlie Norwood. Due to the lack of consistent documentation, the office was unable to determine whether insufficient nurse staffing contributed to the problems. The office identified concerns with compliance with Veterans Health Administration facility requirements related to nursing practices documentation, evaluation of the circumstances surrounding the respiratory care for a patient, processes for securing sitters, and nurse staff assignment practices. The office made six recommendations, which were closed as of Sept. 2, 2021.
  • September 2020: The office found care deficiencies likely contributed to a patient’s death. The office identified other concerns related to documentation, mismanagement of the patient’s mental health needs, deficient Disruptive Behavior Committee processes and oversight, and facility leaders’ insufficient review and response to the patient’s death. The office made 18 recommendations, two of which remained open as of Sept. 2, 2021.
  • December 2020: The office identified deficiencies in care coordination between Charlie Norwood staff and telemedicine intensive care unit staff after general surgery residents were removed by a university affiliate. However, the office was unable to determine that the absence of surgery residents resulted in deaths, injuries, or poor outcomes for patients identified in the complaint. The office found facility leaders were aware of the removal of the residents but did not take action to mitigate potential issues. The office identified other concerns related to communication and coordination, on-call processes, medicine and surgery staff responsibilities, patient safety reporting training, quality review collaboration processes, orientation, and competency training, and coordination of patient care reviews. The office made eight recommendations, which were closed as of Sept. 2, 2021.

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