DAYTON — An inspector general reported that in 2017 the Dayton VA failed to properly care for a patient who died after being admitted to the VA’s emergency department.
An inspection that began as an anonymous complaint to the Veterans Affairs Office of the Inspector General resulted in a debate on whether to suspend a physician and a list of problems for the Dayton VA Medical Center to fix.
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Dayton VA spokesman Ted Froats said the report released Thursday focuses on events that occurred more than two years ago. Since then, the Dayton VA Medical Center has started implementing each of the inspector general’s recommendations, which are expected to be complete this year.
For example, he said the Dayton VA has:
• developed a new policy to ensure timely emergency department transfers and provided clear guidance to staff;
• increased oversight by lowering the threshold that triggers management reviews of our medical providers;
• and standardized all code carts and installed an automated medication dispenser in the resuscitation room, helping ensure patient experiences are consistent.
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“The processes we have developed since the OIG’s visit have helped ensure we continue to provide safe, compassionate, comprehensive care to all veterans,” he said.
The inspector general report said that the office first received the complaint in December 2017.
While investigating the complaint, the inspection team found a number of problems in the emergency department, with a physician who was not named in the report, and with the facility’s operations.
When the patient was admitted to the emergency department, according to inspectors, the physician: ordered a medicine that the patient’s notes said to avoid, significantly delayed in ordering diagnostic tests, didn’t give the patient reasonable medications and treatments for the situationand incorrectly documented that the patient had been moved into another department’s care when the emergency department was still waiting for diagnostic tests.
The investigation found that a CT scan was eventually conducted, but as staff waited for the results a “code blue” was called for the patient, as they went into cardiopulmonary arrest. The responding medical staff couldn’t resuscitate the patient, who died.
Inspectors brought these findings to the facility director, who suspended the physician while facility leadership reviewed the cases.
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After consultation with the chief of medicine and the Veterans Integrated Service Network, the facility’s executive board voted to remove the physician. After appeal, this decision was overturned, but the physician ultimately did not return to the VA, resigning in November 2019.
The investigative team also found a number of problems with the operations of the facility, including: problems with its peer review system, problems with the staff following ordered procedures like using bar codes to track medications and problems communicating between different medical teams that potentially led to harming patients or using unnecessary treatments.
Ultimately, the team 13 recommendations on the problems it found, and the leadership of the Dayton VA Medical Center agreed to follow them, presenting action plans and timelines for the goals to be accomplished.
