Veteran Oversight Now

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'll 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 Health Care Inspections. Trina is a board-certified physician’s assistant who worked at the VA North Texas health care system for eight years prior to joining the VA OIG in 2011.

Welcome, Trina.

Trina Rollins:
Thanks, Fred. Glad to be here.

Fred Baker:
We're glad you're here, as always. We're here today to talk about the report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis. Before we begin and get into the details of the event, can you give us some context on the size and the capabilities of the facility?

Trina Rollins:
I sure can. The Lieutenant Colonel Luke Weathers JR. VA Medical Center is part of VISN 9 VA Mid-South Health Care Network. The facility is a 1A complexity facility, which is the highest level of complexity within VA and has 176 operational beds. The facility is located in Memphis, so as you pointed out, and supports ten community-based outpatient clinics located in Tennessee, Arkansas, and Mississippi.

Fred Baker:
So, this facility was fully capable of responding to this event.

Trina Rollins:
Exactly. Yes. It is the highest level of complexity within the VA.

Fred Baker:
And how did this hotline come to your desk?

Trina Rollins:
So, we received an allegation and that nursing staff failed to recognize an emergent situation for a patient and provide timely medical intervention for that patient, which we believe may have contributed to the patient's death after the patient suffered a very sudden deterioration in their condition.

Fred Baker:
And just briefly, kind of explain how after we receive the allegation, it becomes something that we take on as a hotline inspection?

Trina Rollins:
Sure. Internally, we I have a team that reviews every single health care related complaint that we get. So, we have access to VA medical records, VA policies and directives. So, we're looking at all of those in the context of did anything get missed? We had this patient's name and identifier, so we were able to look in the medical record, to look for missed opportunities.
And then we meet as an interdisciplinary team within the Office of Health Care Inspection to discuss the case. In this case, we did notice there were some discrepancies and missed opportunities that we felt it was enough to warrant opening a hotline and reviewing the entire situation.

Fred Baker:
So, let's talk about the patient. Give us some background. It sounds like there were several health issues for this individual and they were also in their late seventies.

Trina Rollins:
Yes. The patient was in their late seventies and had a medical history that included cutaneous t cell lymphoma, which is a rare blood cell cancer. That cancer can impact the body's ability to fight infection. The patient was diagnosed with sepsis, which is an infection of the bloodstream and acute colon cystitis, which is inflammation of the gallbladder and atrial flutter, which is an abnormality of the heart rhythm.

The patient was admitted to a medical floor with telemetry monitoring, which means they were having their heart monitored continuously.

Fred Baker:
Why did the patient present to the hospital to begin with?

Trina Rollins:
The patient was having signs and symptoms of infection initially.

Fred Baker:
And what made them go to the ICU?

Trina Rollins:
So, they were admitted and were being treated for the infection and their stay was a bit prolonged, which is not unusual with a patient with lymphoma, because, again, their ability to fight off infection is limited. About nine days into the admission, the patient started having respiratory distress or difficulty with their breathing. They were having shortness of breath and decreased blood, oxygen levels and then began needing supplemental oxygen to help keep their blood oxygen levels up.
The patient's breathing continued to decline, so BiPAP was required. And BiPAP is a device that assists the patient with breathing by using a mask, and it pushes pressurized air into the lungs. So, it forces air into the lungs to help the patient breathe. I think, you know, those listening may have heard of a ventilator. That's another type of assisted breathing device, but it's more invasive because you need to insert a tube into the airway and monitor that.
The patient needed to go to the ICU when they were on continuous BiPAP, but initially the patient wasn't sent there. And that's part of the part of the issue here. The facility only allows the continuous use of BiPAP in the ICU. So, when the ICU resident saw the patient, they recommended keeping the patient on intermittent BiPAP, meaning they would turn it on for a few hours, take it off for a few hours, and then use supplemental oxygen when the patient wasn't using BiPAP.
So, they kind of got around the need for the ICU initially. Once the patient's breathing problems continued, a continue to worsen. That's when they noted the need for ICU care.

Fred Baker:
That's what I say, eventually came to a point where they couldn't take him off of the BiPAP, right?

Trina Rollins:
Support him. Yeah, they couldn't support him on the floor. He needed a much higher level of care, which would normally be in an ICU setting.

Fred Baker:
So that was really kind of the beginning of the problems. He was having the trouble breathing. But then he also experienced a sudden drop in heart rate.

Trina Rollins:
Correct, yes.

Fred Baker:
What caused that?

Trina Rollins:
We can't say for sure, but it was likely caused by just worsening of his illness. His organs were starting to shut down. You know, he had this lymphoma. This cancer. He had a pretty serious blood infection. His body was trying to fight that off. He was being given the right medications; the antibiotics needed to fight that. But unfortunately, it you know, it was overtaking the situation.
The infection was winning. And so, the patient started having difficulty with their breathing. And then when the breathing impacted, the ability to provide oxygen to your organs is impacted. And then everything starts shutting down.

Fred Baker:
So, explain what asystolic is.

Trina Rollins:
Sure. It's a term we've used in the report, and it's another word that means the heart has stopped beating, it means that the heart's no longer able to pump blood throughout the body. And in turn, then your body's organs are they're not getting oxygen.

Fred Baker:
So that brings us to the event that I believe centers our inspection, which was the blue alert, correct?

Trina Rollins:
Correct.

Fred Baker:
So, let's discuss what a blue alert is, what conditions necessitate such an alert and kind of who is supposed to respond.

Trina Rollins:
Sure. So, a blue alert our listeners may actually have heard the word code blue before. That's, you know, a similar verbiage for the same thing. It alerts hospital staff when a patient experiences a medical emergency, such as their heart stopped beating or they stopped breathing. It's announced overhead within the hospital and also allows the listener to hear where the emergency is located within the hospital so that staff can then respond to that.
And the type of staff that are going to be responding are physicians and nurses with that critical care type experience, those with advanced cardiac life support certification so that they can address the issues, the emergent issues of the heart, not beating or the patient not breathing emergently. Without intervention, the patient could die within minutes.

Fred Baker:
Is there a time standard then, for response to this alert there?

Trina Rollins:
I mean, there's not a specific time standard. The time standard is as soon as possible. So, when that alert is announced overhead, as many people usually respond as possible. So, you know, this occurred in the middle of the night, early morning hours at Memphis. So, you can imagine that there's limited staff there, you know, present overnight. But when it's when it's heard overhead like that, any physician with ACLS certification, any nurse with ACLS certification will respond.
And so, they understand that it's an emergency. They get there and they start dealing with the emergency.

Fred Baker:
So, there's not a designated team.

Trina Rollins:
There is a designated team. It's a rapid response or code blue team. You know, there are many names for them. It's a physician and nursing staff and other ancillary staff, such as respiratory therapists that are specifically assigned. But again, when you hear that code blue sound, those with the appropriate training, the ACLS certification will respond until that code team arrives.
Once the code team arrives, then they take over the resuscitation efforts.

Fred Baker:
Gotcha. So even though it was in the middle of the night and in relatively low staff there, there are staff designated to respond.

Trina Rollins:
Exactly. Exactly.

Fred Baker:
Just so I back up a little bit. So, they presented they had the infection. They had trouble breathing. They could not be taken off of the BiPAP. They had a sudden drop in heart rate, which you explained, and then they reached this asystolic state. And that's where the code blue was necessary to call, correct?

Trina Rollins:
Yes. Okay.

Fred Baker:
So, there was some miscommunication or appears There was some miscommunication once the alert was sounded. Can you kind of discuss that and the different players that were involved in that?

Trina Rollins:
So, I'll back up just a little bit. When a patient is on a unit and having their heart monitored, it's called telemetry monitoring. And I need to explain that when they're having this telemetry monitoring, there are telemetry techs that actually watch those monitors and are looking for any type of abnormality that may occur in the heart rhythm. But they're not located where the patient is located.
They’re usually centrally located, and they have a bank of monitors, you know, like computer type monitors. And they're watching these heart monitors for these patients and looking for any type of arrhythmias or strange occurrences. That's what happened in this case. So, when the patient's heart started slowing down and then stopped altogether, the telemetry check noticed but didn't follow protocol.
Instead, they tried to call the nurse to determine if the patient was unconscious or, you know, maybe a lead fell off. And that's what was causing the change in the heart monitoring system. I need the audience to understand that the technician is not located on the floor or not located where they have a visual on the patient.

Fred Baker:
And this isn't it. It wouldn't be their role to get up and walk to the to the patient's room to find out, right?

Trina Rollins:
No. No, not at all.

Fred Baker:
So, they're watching. They're watching this bank and they're seeing the monitor. They attempt to call and find out what's causing the and the drop in the heart rate for that particular patient.

Trina Rollins:
Correct. That's what this technician did. What the technician should have done was initiate the blue alert or the code blue when they were unable to reach the nurse after the first attempt. But this this tech tried a couple of different times to reach nurse staff. Once the patient's heart rate completely stopped, that's another indication for calling a code blue or blue alert.
They should have done that immediately at that point in time.

Fred Baker:
So, is this kind of standard for them to try to make this first call to find out what's going on before they do the make the blue alert calls?

Trina Rollins:
So, in our interviews with staff, it seems as though this facility that was kind of the standard. But again, it was it would be the standard if there was an abnormality, not a stoppage. Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue period. No, no making contact at all.
It should have triggered the code blue.

Fred Baker:
And what are other factors that contributed to the delay of getting to this patient?

Trina Rollins:
Sure. We later found out that there was some mandatory nursing training going on during this time frame. And, again, that's not unusual. All medical staff have mandatory trainings from time to time during this night. The mandatory training was scheduled for the nursing staff. The charge nurse is responsible for assigning nurses to cover when a nurse has to leave the unit.
For instance, to go to this training, the nursing assignment and the cross coverage should be communicated to all the nursing staff, but also in this case, to the telemetry technician. So, they know who to contact for each patient in case there's a problem with that patient. So that's part of what contributed to the delay. The telemetry tag was trying to contact the nurse, the originally scheduled nurse, that was assigned to this patient.
But that nurse was in the mandatory training and so didn't respond. And unfortunately, what we finally found out was that the nurse manager didn't assign a specific person to cross cover while the nurse was off the unit attending training.

Fred Baker:
So, at about, about 5 minutes later, the call was made, and they did respond to the patient and. And they were unresponsive, correct?

Trina Rollins:
Correct. They were unable to resuscitate the patient.

Fred Baker:
So, let's talk about the leaders’ response. A lot of times in our reports, we talk about problems with this root cause analysis after events such as this. What did we see there?

Trina Rollins:
So, yeah, so VA provides various specific written guidance on the process for performing the root cause analysis or RCA. They're done to try and determine a root cause for a problem. It's a tool to help the facility determine if there are systemic issues that may result in patient harm. If not done correctly, then the causal factors are overlooked, and the facility has no way of addressing those issues and correcting those issues.
And that unfortunately leaves the patients at continued risk for harm.

Fred Baker:
Well, what were our recommendations here?

Trina Rollins:
So, we made five recommendations to the facility director related to ensuring nursing service adheres to cardiac telemetry monitoring policies. Charge nurses make nursing assignments appropriately. ICU physicians document complete written responses to critical care consults and Quality Management and Performance Improvement Service conducts administrative reviews and root cause analyzes in accordance to policy. We also asked the facility to consider completing another RCA to review this patient's event.

Fred Baker:
And what was their response?

Trina Rollins:
So, we actually got we got a response from the VISN network director who reviewed the recommendations and concurred, and the facility director responded that additional reviews have already been conducted to discover the contributing factors that the facility could improve the system issues. Those included communication issues, hospital policy issues and staff training.

Fred Baker:
And we’re we satisfied with those responses?

Trina Rollins:
So, we will continue to monitor them until we've seen enough evidence that leads us to believe that it's been addressed appropriately.

Fred Baker:
Well, Trina, this was a very unfortunate and sad event that resulted in the patient's death. Hopefully, there are some lessons learned from the work we've done. Is there anything else you would add to this?

Trina Rollins:
No, I think that's I think it's a really well-written report. So, again, it's got a lot of information about ICU care, telemetry type care and what's required to cover the patients in those in those areas. If a nurse happens to be off the unit.

Fred Baker:
Well, thank you very much. We always appreciate your insight into these reports. Thank you very much.

Trina Rollins:
Thanks, Fred.

Fred Baker:
As I mentioned in this podcast, you can submit a complaint to the VA OIG by phone 1-800-488-8244. Or you can go to our website www.va.gov/oig/hotline and fill out a hotline complaint there. However, if you are a veteran in crisis or someone who is concerned about one, please call the veteran crisis line.
Dial 988 and then press 1. Now let's go to Lauren for the highlights of our oversight work for this past month.

Lauren O’Connor

Thanks, Fred.

The VA OIG’s Office of Investigations is staffed by special agents with full law enforcement authority, forensic auditors, and other professionals. Staff use data analytics, cyber-tools, covert operations, and other strategies to detect and address conduct that poses a threat to or has harmed veterans or other beneficiaries and VA personnel, operations, and property. Thirteen investigations had significant developments in March. I’ll highlight a couple.

A multiagency investigation resulted in charges alleging that 10 doctors, two pharmaceutical executives, and two management service organizations participated in various healthcare fraud schemes. This included paying illegal kickbacks to physicians for prescriptions, automating prescription refills regardless of medical necessity, and providing and billing for unnecessary prescriptions. Government and private insurance programs were billed approximately $445 million. VA’s Civilian Health and Medical Program and Office of Workers’ Compensation Program were billed over $16.8 million. Of this amount, VA had paid approximately $1.9 million. The defendants were indicted in the Northern District of Texas on charges including conspiracy to violate the Travel Act by violating the Texas Commercial Bribery Statute, conspiracy to deny patients their right to honest services, and conspiracy to commit money laundering.

In another case, an investigation by the VA OIG, Department of Transportation OIG, and Social Security Administration OIG revealed that a veteran received VA individual unemployability and Social Security disability benefits because he maintained that he was unable to work. Meanwhile, the veteran owned and operated two construction companies that were designated as service-disabled veteran-owned small businesses. The veteran also withheld information on multiple FAA medical certifications in order to obtain a medical certificate to receive a pilot’s license. The information concerned a service-related disability for which he received both VA and Social Security Administration disability benefits. A federal jury found him guilty at trial of making false statements to the FAA in February 2024. The jury was deadlocked on the theft of government fund charges pertaining to VA and the Social Security Administration. The veteran pleaded guilty in the Western District of Louisiana to theft of government funds to resolve the remaining charges. In accordance with the plea agreement, he forfeited previously seized funds totaling over $141,000.

Other offices within the VA OIG conduct audits, evaluations, and inspections to help improve the efficiency, effectiveness, and integrity of the VA’s programs and services. The findings are then summarized in reports published on our website.
The VA OIG published 20 reports in March, including two management advisory memoranda. The OIG issues memoranda when exigent circumstances or areas of concern are identified by OIG hotline allegations or in the course of its oversight work, particularly when immediate action by VA can help reduce further risk of harm to veterans or significant financial losses.
The Office of Audits and Evaluations issued the memo Scheduling Challenges within the New Electronic Health Record System May Affect Future Sites. The new electronic health record system for VA patients includes a scheduling component intended to enhance scheduling efficiency and user experience. However, our team identified scheduling challenges, including the need for additional staffing and overtime, inaccurate patient information, and the inability to automatically mail appointment reminder letters. These deficiencies result in inconsistent workarounds and additional staff effort, which increases the risk for scheduling errors. This memo highlights concerns that these challenges could have an even greater impact at larger, more complex medical centers and helps VHA determine whether additional actions are warranted for future deployments.

An Office of Healthcare Inspections report revealed that staff did not properly reprocess reusable medical equipment within the Sterile Processing Service. The facility also had potentially harmful, abnormal critical water test results. In response, all endoscope use was halted, and surgeries and procedures requiring reusable medical equipment stopped until an investigation was completed. The OIG identified multiple issues that contributed to Sterile Processing Service deficiencies, including previously identified issues within the Service that had gone unaddressed. These issues include the failure to implement a system that tracks instruments from the beginning of reprocessing through transporting, storing, and use; outdated standard operating procedures; and the lack of consistent leadership within the Sterile Processing Service. The OIG made nine recommendations to address these deficiencies, including two recommendations to the VISN director and seven recommendations to the facility director.

This month’s reports also included nine Comprehensive Healthcare Inspection Program reports, also called CHIP reports. These inspections are performed approximately every three years for each facility, and the OIG selects and evaluates specific areas of focus on a rotating basis.

The March CHIP reports featured VA medical facilities in New Hampshire, North Carolina, Alabama, West Virginia, Pennsylvania, Wisconsin, Michigan, Wyoming, and South Dakota.

Thank you for listening to March’s highlights. Visit our website for all VA OIG podcast episodes.

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. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. 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.