The Veterans Affairs Office of the Inspector General released a report Feb. 20 detailing patient care issues at Dayton (Ohio) VA Medical Center that may have contributed to the death of an elderly patient, according to a Dayton Daily News report.
The VA OIG first received complaints about the hospital in December 2017, alleging the hospital's emergency department and a registered nurse made errors that were related to the death of the patient.
During the inspection, the VA OIG found that there were problems with the ED's handing of the patient and facility operations. A physician was implicated as well, but not an RN.
The report shows that when the patient was admitted to the ED, the physician put in an order for a drug that the patient's notes made clear should not be used. There was also a significant delay in putting in diagnostic test orders and incorrect documentation of the patient being moved to another department, though the ED was still waiting for test results.
The patient went into cardiopulmonary arrest while staff was waiting for CT scan results. The patient died soon after.
The physician was suspended, and despite appealing the executive board's decision to remove the physician, the physician resigned in November 2019.
The inspection also found issues with the facility's operations, including its its peer review system communication issues that could result in patient harm.
The VA OIG made 13 recommendation to the hospital, which it agreed to follow, presenting the OIG with an action plan. The OIG will follow up with the facility to ensure it has implemented the action plan.
A spokesperson for Dayton VA Medical Center told Becker's that the hospital has started implementing each the OIG's recommendations and expects to implement them all this year, including a new policy to ensure timely emergency department transfers.
"The Dayton VA emergency department has safely cared for more than 75,000 veterans without incident and developed processes to ensure the facility continues to provide safe, compassionate, comprehensive care to all veterans," the statement said.