Deficiencies in Ambulatory Care Center and Emergency Department Processes at the VA Loma Linda Healthcare System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation that a patient died in the Emergency Department waiting room at the VA Loma Linda Healthcare System. The OIG did not substantiate the allegation. The facility policy did not require the first look nurse, who assigned an Emergency Severity Index level 3 (1–most urgent to 5–least urgent) to the patient, to take vital signs. Two hours later, the triage nurse obtained the unarousable patient’s first set of vital signs and documented a rapid heart rate. Following transport to an Emergency Department room, a physician noted no heart sounds and no pulse. The family declined life sustaining interventions and the patient died shortly thereafter. The OIG determined that Emergency Department staff followed triage protocols. Mental health clinic nursing staff at the Ambulatory Care Center failed to assess and document the patient’s condition during maintenance care for a urine catheter bag. Although the omission may not have affected the patient’s care, complete and accurate documentation is essential to coordinating and providing comprehensive care. The OIG found that primary care nursing staff did not provide a hand-off communication to the Emergency Department but was unable to determine if this affected the patient’s outcome. The facility addressed 9 of 11 systems issues identified by its fact-finding review completed after the patient’s death and planned to address the remaining issues in fall 2020. The facility revised the first look nurse policy to require obtaining and documenting a patient’s vital signs within 10 minutes of arrival but had only 65 percent compliance with the updated policy. Three recommendations were made to the Facility Director related to providing documentation training for mental health clinic staff, reviewing the hand-off communication policy, and ensuring compliance with the revised first look nurse policy.