Veteran Oversight Now

Veteran Oversight Now “Hotline Edition”
Season 2, Episode 8

Related Report:
Episode Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas
Published: 6/28/2023
Report #22-02725-132

Fred Baker:
Welcome back to another episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker. Each month on this podcast we will bring you highlights of the OIG's recent oversight activities and interview key stakeholders in the office’s critical work for veterans. This is a special hotline edition of Veteran Oversight Now and joining us today is Trina Rollins. Trina is the director for hotline coordination within the VA OIG's Office of Healthcare Inspections. Trina is a board-certified physician assistant who worked at the VA North Texas Healthcare System for eight years prior to joining the VA OIG in 2011. Welcome Trina.

Trina Rollins
Thanks, Fred. I'm glad to be here.

Fred Baker
Trina, we're again here to study one of our reports and gather some lessons learned that hopefully those within the VA community can take and apply and hopefully avoid some of the tragic events that we do have to discuss. Today, we're talking about the quality-of-care concerns and the facility response following a medical emergency at the VA Southern Nevada Healthcare System in Las Vegas. Do me a favor Trina, before we talk about the event, characterize the facility where this event is happening.

Trina Rollins
Yeah. So, the facility is part of Vision 21, and it's a level 1B complexity, meaning it's a pretty high complexity. It has 130 operational beds which provide medical, surgical, and mental health services. The facility has associated with it seven outpatient clinics located in Nevada and one of those outpatient clinics is where this incident occurred. At that clinic, there is no emergency department. So, when you first read the report, you may wonder why didn't they take him to the emergency room? Well, in this case, there wasn't an emergency room. This was an outpatient clinic not associated with the hospital. I believe it's about 11 miles from the actual facility. So again, it wasn't a quick trip to take him. It wasn't across the campus or anything. So yeah, so they had to make decisions on the spot as to how to treat the patient.

Fred Baker
And that's a good point. So, we may as well go ahead and jump into the event. Can you characterize the patient and what the patient was being seen for at the clinic that day?

Trina Rollins
Sure. So, he was actually there for a routine appointment, but this gentleman was in his 80s and had a lot of cardiac problems, known cardiac problems through the years. And so, he had, in 2018, had been diagnosed with cardiovascular disease and had actually declined having any type of bypass surgery to correct that. And so as per his choice, they tried to treat it as best they could medically. He had high blood pressure, which was treated with medication, and he had actually showed up to the clinic four days prior and saw a nurse because he'd been having dizzy spells and falls at home. And unfortunately, at that point in time, the nurse didn't take any vital signs to check to see if maybe his blood pressure was low, or he was having an irregular heartbeat related to his cardiac problems to explain why he was having dizziness. The patient felt it was related to his medications, so he had stopped one of his blood pressure medications and let the nurse know that. The nurse then gave the instruction to just come back to the clinic in four days when his regularly scheduled appointment was scheduled and talked to the doctor about it at that point in time.

Fred Baker
So, let me ask you, the patient was using a walker, so he already had some motor skills or how do characterize it?

Trina Rollins
Balance. Yeah, I would probably. Yeah. He was having difficulty with his gait. The way he walked in, and most likely balance problems because of the dizziness he was experiencing.

Fred Baker
Right. And he said he told the nurse that it made him feel like the room is spinning.

Trina Rollins
Correct, yeah.

Fred Baker
So, the patient came back four days later. Kind of walk us through the events that happened that day, in that appointment.

Trina Rollins
Sure. So, he comes back for his routine appointment. And if you've ever gone to an appointment in the VA, you check in. You get seen by a nurse first. The nurse asked him questions, determined if he was having any problems. And again, he mentioned that he was having dizzy spells and was having falls and thought it was related to his blood pressure medication. The nurse at that time did take some vital signs and the abnormal vital sign was his heart rate. It was elevated. And so that was all noted in his medical record before he saw his physician. So, the primary care physician took into account all of the information from the vital signs, and the nurse ordered some additional labs, a chest x-ray, head imaging, and a consult for fall prevention clinic, which again is to help the patient. It would evaluate the patient's gait and then make some recommendation as to what might help him prevent falls in the future. Those are all great interventions, but it would take time to get all of those interventions.

Fred Baker
That's what I was going to say. All of these appointments weren't going to happen that day.

Trina Rollins
No, no, none of them were.

Fred Baker
So meanwhile, he's still dizzy.

Trina Rollins
Still dizzy, still falling, and the PCP actually made a call to his roommate, who we believe was in the parking lot in the car. Just as a reminder, this was occurring during the time of COVID, and so visitors to the clinic were limited. This patient came into the clinic by himself, but the PCP took the time to call the roommate. And the roommate said, you know, this veteran had been falling quite a bit. I believe it was six times in the last month or so.

Fred Baker
So, he was given the referrals. But nothing was going to happen that day. What happens next?

Trina Rollins
The appointment was done. The patient finishes his appointment and walked out into the waiting area, presumably to wait for his labs to be drawn. The PCP had remember ordered additional lab studies, but as he was headed towards seating area, he fell, landed on his back, and then that's when the incident occurred, the fall occurred, and the corresponding emergency response happened.

Fred Baker
Right. Trina, I want to bring up here that there is a video, a waiting room video, of the fall that was aired on a local media station. They got the video through a FOIA request, a Freedom of Information Act request, and that video is out and public. So, we can see everything that led up to the need for the emergency response due to his fall and then the subsequent actions taken afterward from the perspective of that camera.

Trina Rollins
So yeah, I want to point out that this this fall occurred in the spring of 2021. We did, as we as in the OIG, did get a complaint related to it, but we didn't have enough information to actually review it at that time. We didn't have the patient name, and then the date of the incident provided was incorrect. So, we could not match it up. A year later, when a local news outlet aired the story and the video, we actually got a request from Senators Catherine Cortez Masto and Jackie Rosen to review this and make sure that VHA had done the correct things when this emergency happened. We started our inspection, and we tried to focus on the care provided and then the facility response following the medical emergency within the clinic. The video does not have any audio associated with it, so again, you're looking at the video, but you can't hear anything that's happening in the background. And so again, that makes it a little bit more difficult to piece together what's going on. But you can see in the video that the patient fell, landed on his back, and it took approximately two and half minutes before a nurse actually arrived. You can see there are people in the lobby that are yelling. We don't know what they're saying but presuming they're trying to get help for the veteran. That nurse placed a pulse oximeter on the patient, and a pulse oximeter is a little machine that actually takes your pulse rate, tells you how well your oxygenating, so how much oxygen is flowing through your bloodstream. That's a good indication of whether or not you're getting good oxygen or not. The nurse then starts moving her hand from the patient’s chest to his neck. If you have learned basic life support through the American Heart Association, the most important thing is to start chest compressions as soon as possible when you know someone doesn't have a pulse. Part of that rescue breathing and rescue compressions is checking to see if a patient has a pulse, checking to see if the patient is breathing. If they're not, then you have to artificially press on the chest to try and mimic blood flow.

Fred Baker
There was a VA policeman there first. There were other medical professionals. I assume any number of those should have been CPR qualified.

Trina Rollins
Every single person, medical provider, in the clinic had training in basic life support including the VA police. In the video, you can actually see the VA police officer is the one that went and got the AED, the automated external defibrillator. So, that's the next step in basic life support. You put that machine on to see whether or not the patient has any type of heart rhythm. If the patient doesn't have a heart rhythm, then you use that machine to electrically shock the patient to help reestablish a heart rate.

Fred Baker
So why the delay?

Trina Rollins
That's a really good question, and I think that's the point of this, or the takeaway is the first nurse that arrived heard an emergency was occurring. I do want to make a point of saying that the overhead paging system within that clinic was not working properly. The overhead page could be heard in the vicinity of the lobby, but not back in the clinic where most of the providers and nurses were located. And this was a known problem. This was a leased building, and the VA was working with the owners of the building to try and get that corrected. But again, this was in the middle, you know, in the midst of COVID and trying to get repairs to the building may have, you know, that may have contributed. I can't say it did or didn't, but it may have.

Fred Baker
Regardless, it was under repair, and it was not working correctly.

Trina Rollins
It was not working properly. The nurse that arrived came with a blood pressure, an electronic blood pressure machine, so again that could take the blood pressure and the pulse of the patient. But she didn't start CPR. And again, this is a clinic where these types of emergencies don't happen every day. They don't even happen every month. An outpatient clinic like this may get one or two of these emergencies a year. The staff are not going to be really sharp when these types of events happen. When we interviewed the nurse, she was concerned that the patient had a head injury because in the video you can actually see there's blood seeping from the patient's head and kind of pooling around his head. You know, that's what she said. She thought the chest compressions may impact his head injury. But again, you know, basic life support is to try to get that heart pumping as soon as possible.

Fred Baker
Eventually she did come to the conclusion that she needed to start CPR, correct?

Trina Rollins
Yeah. When we interviewed her, she, you know, she did say in hindsight, she should have started CPR first. But in the same interview she did admit being concerned about worsening head injury. And, you know, again, you can actually see the blood pooling around his head.

Fred Baker
Did anyone begin CPR?

Trina Rollins
So yes, other staff had arrived by that time, and the original nurse was helping to put the AED pads on the patient's chest. A different nurse had started chest compressions. They continued chest compressions until the paramedics arrived, approximately 12 minutes after the patient fell.

Fred Baker
So, what happened then?

Trina Rollins
The paramedics arrived, took over the chest compressions and life support, and transported the veteran to the nearest hospital, which was a community hospital, and the patient was pronounced dead at that local hospital.

Fred Baker
And I want to make sure we point out, even though we are discussing the delay in CPR in our report, we make it clear that we were not able to determine that the delay in initiating CPR actually led to the patient’s death.

Trina Rollins
That's correct, Fred. You know, we want to make the point because this patient had a pretty extensive cardiac history. You know, by looking at the video, we can't tell if his heart stopped and that's what caused the fall. Or if he fell, and because of that trauma, then his heart stopped. We don't know where in that occurred and you can't make that type of inference using a video with no audio. And again, we're not able to see the pulse oximeter reading, you know any of those vital signs, so we can't make that judgment. He had this pretty severe cardiac history. The point we're trying to make in this report is there was a process that should have been followed. It wasn't followed. We can't say whether or not if the process had been followed to the letter it would have saved this veteran.

Fred Baker
So, we identified that there was a delay in initiating CPR, and we identified that the emergency notification speakers were ineffective. What else did we find?

Trina Rollins
The nurse that saw the patient four days prior to his routine appointment didn't take any vital signs, didn't have any type of discussion with the primary care provider to alert them of the patient’s falls or his dizziness. And then again, the same day of the appointment, the PCP ordered a lot of studies, labs, x-rays, head imaging, consult. But didn't do anything at that moment to determine whether or not this patient was safe to go home. This patient then ended up in the lobby falling, injuring his head, having cardiopulmonary arrest. You know, additional testing such as an EKG or additional vital signs such as orthostatic vital signs where you're taking blood pressure and heart rate in the lying down, sitting, and standing positions could show whether or not there was additional issues to be dealt with, and none of that was done.

Fred Baker
Sure. Sure. I also want to talk about the leaders’ response because that's important too when evaluating lessons learned from an event. If it's not done correctly, then they miss out on opportunities to correct later performance.

Trina Rollins
Correct. Yeah. Yeah, you're exactly right. There was an after action debrief done, which is a normal process two days after the incident. So again, very quickly afterwards, there was education to staff related to the medical emergency response process. They made sure everyone in the clinic had their basic life support up to date and all of that occurred within two weeks of the incident. Then the facility actually went further, a step further, and made sure that all clinics, all of the outpatient clinics, were educated on the same thing. The medical emergency response and all staff were up to date with their basic life support within three months of the incident. So, they took that extra step. When they were actually reviewing the incident, though, we felt they could have done that a little better. They made the assumption that the patient had cardiac arrest, which caused his fall, and we don't know that. We can't know that because we don't know what the vital signs were. So, when you make those assumptions, you limit the way you review the issue. If they had left it open, they may have done more review of the clinical aspects of care, but what they did do was review the emergency response and made appropriate adjustments and provided appropriate education, and they've actually started doing those drills to help keep staff up to date and responsive to those types of emergencies. The other thing that they did, which I thought was commendable, is that they have a daily schedule now of the specific role each staff member should play if an emergency occurs. So again, they identify who's responsible for getting the AED, who's responsible to be the leader if they are having to do some type of emergency response. When you have a leader, you know that person says I need vital signs, I need a blood pressure, we need to...they're leading what the rest of the staff should do. So again, you know they made the…they've taken the step now to actually identify that every single day. And so, it's helpful for the staff because they know what their responsibility is and they're not stepping over each other or duplicating efforts.

Fred Baker
So, it sounds like there's there has been progress already.

Trina Rollins
Correct. Yeah.

Fred Baker
What were some of our recommendations?

Trina Rollins
So again, some of the recommendations related to ensuring there was a proper response to a medical emergency in the clinic, ensuring compliance with CPR documentation in the outpatient clinics, again without that CPR documentation, it's really hard to do those after action debriefs if you don't have the information. If you don't know and you know in this case did the patient have good vital signs or not? You don't know how to review the incident. Another recommendation was ensuring that all plans developed after the action, after action debrief, is actually implemented. You know, their debrief had several recommendations and they put into action those plans and then they went ahead and actually moved it into all of the clinics and had that same education. So, we want to ensure that that is implemented across the board so that all the clinics are working with the same set of guidance.
The other thing is we recommended that the facility work with the Office of General Counsel to determine if an institutional disclosure was warranted. The institutional disclosure is actually when a facility reviews some type of adverse event and makes a determination that there was room for improvement is what I'll say in this case. We can see from the video there was a delay in instituting basic life support. So, you know that is something we felt would be important to relay to the family member or the significant other in this case. So, we've asked the facility to consult with General Counsel to see if they feel an institutional disclosure is warranted. They recommended evaluating staff’s understanding of advanced care planning, advanced directives, and life sustaining treatment decision processes. This really comes into play in an inpatient setting because again, you don't want to do additional testing, give additional treatment, when a patient that is not the patient's wishes. You usually ask me how the facility responded…

Fred Baker
I was just getting ready to ask. Based on what you said earlier though, it sounds like they received it well.

Trina Rollins
They did. The VISN and the medical center director concurred with our recommendations, but again, the medical center director did want to make a point of saying that, you know, many of these improvements in the emergency responsiveness occurred actually before we got involved. And so, we wanted to make sure, you know, that is in the report and if you, you know, if you look at the report, you'll see, under the medical center director’s comments, he did make the point that, you know, emergency responsiveness, in those outpatient clinics, has resulted in stronger practice improvements in emergency situations.

Fred Baker
And while that's good and that is very good, actually, that still doesn't negate the value of us going behind and looking at this incident to ensure that that all of the lessons learned were captured.

Trina Rollins
Exactly. And so, we wish it wouldn't have happened of course. Since it's happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome for the veteran.

Fred Baker
Well, Trina, thank you very much. Is there anything else you would like to add?

Trina Rollins
No, I think that's it.

Fred Baker
Well, thank you very much.

Trina Rollins
I appreciate you. Yeah, I appreciate it.

Fred Baker
Yeah. Well, Trina, again, I appreciate you being here on the on the podcast today. And with that I will turn it over to co-host Mary for the monthly highlights.

Mary Estacion
Thanks Fred.
Out of the Office of Investigations, comes news of a healthcare investigation involving multiple companies and individuals in connection with a foreign medical program fraud scheme. An investigation by the VA Office of Inspector General and the US Department of State’s Diplomatic Security Service resulted in charges alleging that 12 individuals and 24 companies participated in a long-term scheme that targeted veterans overseas. The defendants allegedly created a network of medical and pharmaceutical service providers that submitted thousands of false claims to VA’s Foreign Medical Program for services that were double billed, grossly overpriced, unnecessary, or not rendered. They then deposited and transferred proceeds received from VA and their private business entities among several banking institutions to disguise their illicit activities. The total loss to VA is approximately $67 million. The Panamanian judicial system is prosecuting this case as a result of a filing by the Department of Justice in coordination with the US Embassy in Panama.

Another VA OIG investigation involves the FBI where a veteran was charged with allegedly sustaining accidental self-inflicted gunshot wounds after making illegal modifications to his military-issued rifle, which caused the weapon to go off during a convoy mission in Iraq. The defendant then allegedly fraudulently obtained a Purple Heart for that gunshot wound and a 100 percent service-connected disability rating from VA for several issues, primarily caused by the accidental shooting. The total loss to VA is approximately $650,000. The veteran was indicted in the Southern District of West Virginia on charges on healthcare fraud.

From the Office of Audits and Evaluations, comes a report that finds additional measures would better protect borrowers from risks associated with interest rate reduction refinance loans. This audit focused on whether oversight of interest rate reduction refinance loans (IRRRLs) by the VBA’s Loan Guaranty Service ensures veterans are protected from unfavorable refinancing and unallowable or unreasonable refinance charges. The OIG concluded that new controls implemented by the Loan Guaranty Service by May 2020 improved oversight of IRRRLs but did not fully protect borrowers from unfavorable refinances due to closing cost overcharges. These estimated potential charges amounted to roughly $3 million and affected approximately 18,400 FY 2020 borrowers based on the audit sample. The Loan Guaranty Service lacked controls and sufficiently detailed guidance to fully perform loan oversight and quality assurance. By implementing the nine recommendations the OIG made, the Loan Guaranty Service can more effectively protect borrowers from unfavorable IRRRLs and help ensure that VA is guaranteeing loans that comply with program requirements.

A report from the Office of Healthcare Inspections focused on a concern with the Veteran Health Administration’s Lung Cancer Screening Program Requirements. VHA has 10 mandatory elements that must be in place for a facility to establish this type of program. Lung cancer is the leading cause of cancer deaths in the United States, where screening rates remain low. Although it generally has a poor prognosis, diagnosis at an early stage improves patients’ survival. The OIG found that VHA guidelines presented barriers to broader adoption of LCS and did not ensure consistent implementation. Just over half of surveyed VHA facilities reported having an established LCS program. Three recommendations were made to the under secretary for health that addressed the operational memorandum for LCS implementation and the lack of a requirement to offer eligible patients the screening.

The featured report from the Office of Healthcare Inspections is an OIG look at VHA’s Severe Occupational Staffing Shortages for Fiscal Year 2023. The OIG annually determines a minimum of five clinical and five nonclinical VHA occupations with the largest staffing shortages within each VHA medical center (facility). The OIG also compares the number of severe shortages against the previous four years’ reports to assess changes. Facilities reported an increase in severe shortages in FY 2023 over the prior year, following annual decreases between FY 2018–FY 2021. Eighty-eight percent of facilities reported severe shortages for medical officers and 92 percent reported severe shortages for nurses. Practical nurse positions were the most frequently reported clinical occupation with severe shortages, while the most frequently reported nonclinical occupation with severe shortages was for medical support assistance. All 139 facilities surveyed reported at least one severe shortage. The total number of severe shortages increased by 19 percent from Fiscal Year 2022.

The Comprehensive Healthcare Inspection Program (CHIP) continues to be a critical element of the OIG’s overall efforts to ensure that the nation’s veterans receive high-quality and timely VA healthcare services. The inspections are performed approximately every three years for each facility. The OIG selects and evaluates specific areas of focus on a rotating basis. This month’s CHIP reports focused on 7 facilities: The VA New York Harbor Healthcare System in New York, the Southern Arizona VA Health Care System in Tucson, three health care systems in California: the one in San Francisco, Palo Alto and Greater Los Angeles, and two in Pennsylvania, specifically Butler and Lebanon.

Finally, the featured case from the OIG’s Hotline staff focuses on EKGs or electrocardiograms. The OIG hotline received a complaint alleging that insufficient staffing led to EKG reports not being read at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. The matter was referred to the local Veterans Integrated Services Network, or VISN 20, which manages the day-to-day functions of medical centers in the Pacific Northwest region. The VISN 20 staff determined that 22 of 519 EKG reports dating back to September 2022 were in a completed/unsigned status. The lack of a formal process to routinely identify incomplete cases led to the unsigned reports. The 22 unsigned EKG reports were completed by medical center staff in Walla Walla by May 15, 2023. They further disclosed similar findings from a review of additional EKG reports from medical centers within VISN 20 in Roseburg and White City, Oregon. Beginning in August 2023, the VISN’s Quality Management and Oversight office and Chief Nursing office created a plan to establish formal monthly reporting to the VISN’s electronic health record modernization steering committee.

For more information about these and the other activities the VA OIG has been working on, go to our website at va.gov/oig. If you want to get e-mails whenever the VA OIG publishes a new report or issues a congressional statement, you can sign up with GovDelivery by going to our website and click on ‘email alerts’ under the section labeled ‘Stay Connected’.

Check out other episodes wherever you listen to podcasts.

Stay tuned for more highlights next month. Thanks for listening.

This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/OIG. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports and keep up to date on the latest criminal investigations. Report potential crimes related to VA waste or mismanagement, potential violations of laws, rules or regulations, or risks to patients, employees, or property to the OIG online or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800-273-8255, press one and speak with a qualified responder now.