Investigation indicates VA staff failed to resuscitate patient in 2016

BUFFALO, N.Y. (WIVB) – The Department of Veterans Affairs Inspector General’s Office says that the Buffalo VA Hospital failed to resuscitate a patient suffering cardiac arrest in late 2016.

According to a report released Tuesday, the facility director contacted the Office of the Inspector General’s Criminal Inspection Division in Jan. 2017 to report the death of a patient who did “not receive immediate
life-sustaining treatment after staff determined the patient was unresponsive.”

The facility director reported that a registered nurse didn’t “call a code” after finding the patient unresponsive because the RN didn’t want to put the patient’s body through trauma, such as cracked ribs which it was feared CPR or chest compression would cause, as the patient was frail. The OIG was not able to determine a time of death.

The nurse believed that the patient had been dead for 20 minutes and that performing CPR would crush his chest.

The registered nurse (RN 1) and a respiratory therapist acted outside their scopes of practice and violated Veterans Health Administration (VHA) and Facility policy when they announced that the patient was dead, “which influenced others not to take appropriate action”, the report states.

Another RN tasked with monitoring patients’ cardiac rhythms (RN 2) and a licensed practical nurse failed to activate a Code Blue response. The report says RN 2 also abandoned the telemetry desk during the event, temporarily placing other monitored patients at risk.

“We determined that a series of failures relating to the telemetry monitoring of the patient contributed to the delayed response to the patient’s cardiac arrest. Specifically:

• RN 2 failed to recognize cardiac rhythm changes that required immediate action.
• RN 2 incorrectly interpreted the patient’s lethal cardiac rhythm as a benign,
perfusing rhythm.4
• The telemetry system recorded the sounding and silencing of multiple red
alarms5 relating to the patient’s cardiac arrest, with no corresponding evidence of
actions being taken (such as notifying the patient’s assigned nurse or charge
nurse to take action)”

After the patient died, the facility failed to immediately remove the e involved staff from all types of direct patient care duties pending an investigation, as well as failed to call a review.

“In addition, facility leaders did not submit an Issue Brief to the Veterans Integrated Service Network, and did not pursue notifying the patient’s family or personal representative after identifying staff failed to appropriately respond to the patient’s cardiac arrest,” the report stated.

The office recommended the following to the facility director:

• Review the care of the patient who is the subject of this report and confer with
the Office of Human Resources and the Office of General Counsel to determine
the appropriate administrative action to take, if any.
• Ensure that staff conduct interprofessional mock code training throughout the
Facility with debriefing and monitor outcomes.
Mismanagement of a Resuscitation and Other Concerns, Buffalo VA Medical Center, Buffalo, NY
VA Office of Inspector General iv
• Conduct an evaluation inclusive of but not limited to unit 9B and the Respiratory
Department to determine if there are issues undermining teamwork at the work
place, take action to address those issues, and monitor compliance.
• Ensure that staff adhere to the Facility’s telemetry policy including, but not limited
to, saving rhythm strips when a patient has a change in his/her baseline or a
significant arrhythmia, that a competent staff member is always at the telemetry
station, and that facility managers monitor compliance.
• Ensure that the Facility’s Education Department staff review the adequacy of its
annual telemetry monitoring re-certification process including, but not limited to,
evaluating whether to institute additional requirements for staff who rarely have
practical experience in telemetry monitoring and establishing procedures to
ensure that re-tests are conducted and tracked appropriately, and monitor
• Evaluate the Respiratory Department handoff communications process including
the timing of patients’ treatments and code status, and modify as appropriate.
• Ensure staff assess patients before and after breathing treatments, document the
patient’s response in the electronic health record, and monitor compliance.
• Review the content of Facility staff’s communication to the patient’s family and
take corrective action if it is determined that the communication was insufficient
to convey that the Facility was disclosing potentially inadequate care.


The Buffalo VA offered the following statement Tuesday:

We appreciate the Office of Inspector General’s oversight, which is precisely why VA Western New York Healthcare System leadership self-reported this incident to the OIG.
Secretary Shulkin has made it clear that he will hold employees accountable when the facts demonstrate that they have failed to live up to the high standards veterans and taxpayers expect, and that’s exactly what we will do in this case.
In the meantime, VAWNYHS wants to assure veterans and their family members that our facility is a safe environment and our employees remain dedicated to providing quality health care.  
We continue to work with veterans, community stakeholders and local and national VA leaders in order to complete all of the inspector general’s recommendations. provides commenting to allow for constructive discussion on the stories we cover. In order to comment here, you acknowledge you have read and agreed to our Terms of Service. Commenters who violate these terms, including use of vulgar language or racial slurs, will be banned. Please be respectful of the opinions of others. If you see an inappropriate comment, please flag it for our moderators to review. Note: Comments containing links are not allowed.

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