Mismanagement of a Resuscitation and Other Concerns at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate care of a patient who died in a behavioral health unit at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi. The specific concern was the unit staff’s failure to initiate full resuscitation efforts when the patient was found unresponsive (event). Behavioral health unit registered nurses (RNs) did not fulfill the position responsibilities or ensure accurate documentation for the patient. Unit staff did not initiate appropriate resuscitation efforts after finding the patient unresponsive. The OIG was unable to determine whether initiating full resuscitation efforts would have been successful if employed at the time the patient was found unresponsive. An RN inappropriately determined the patient’s death; staff did not consistently track documentation of the behavioral health unit RNs’ basic life support competency and training; and emergency department providers did not document a discussion with the admitting behavioral health provider. The behavioral health unit’s emergency cart was unlocked and contained an expired tubing package. The OIG identified deficiencies in the facility’s response to the event that included the reporting requirements to the State Licensing Board and consideration of an institutional disclosure. Despite the claim that staff initiated resuscitation for the patient, the OIG did not find documentation of therapeutic measures on required forms and the designated committee did not review the event. The OIG made nine recommendations related to emergency/code blue procedures, pronouncement of death, health record documentation, and review processes.