VA Let Full-Code Patient Die Without CPR

By Walter F. Roche Jr.

Staff at a Veterans Administration facility in Michigan, acting on misinformation from a nurse, did not attempt to resuscitate a patient who had asked to be given full code status.
That was the conclusion of the VA's Inspector General in a 20-page report issued Tuesday. The incident occurred at a VA facility in Ann Arbor, Mich. late last year.
"We found that the staff at the system did not provide CPR to a patient with full code resuscitation status," the report states.
According to the IG, the nurse who provided the misinformation had been the subject of administrative action following incidents in 2012 and 2015. The male nurse was subsequently transferred to a position not involving direct patient care.
The nurse who was the primary staffer assigned to the patient told one fellow staffer that his patient was "Do not resuscitate." That misinformation was subsequently passed on to other members of the response team and none actually checked the patient's record to verify the information.
The nurse, the IG found, "relied on memory and did not recheck the status of the patient during the event."
Noting that the patient had a cardiac history and had an incident in the hours before his death, the report states that "it is not clear whether resuscitation efforts would have been successful if employed at the time."
The report cites a series of failures in policies and procedures at the facility that permitted the error to occur'
The IG noted that the Joint Commission, which sets standards for health care facilities, "requires that all staff involved in a patient's care and treatment be aware that the patients has an advance directive."
Also noted was the fact that the although the patient was in a unit in which patients were on electronic monitoring, he was not.
Had he been on telemetry monitoring, the report states, the cardiac arrest might have prompted other staffers to check his code status.
"At this point," the report states, "it is not clear when each of the staff became aware that the patient had stopped breathing."
Finally the report states that facility administrators had noted a potential vulnerability in their processes a year earlier but they never took corrective action.
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