Paul Muschick: How poor care at a Pennsylvania VA hospital may have contributed to veteran's death

Sep. 24--There were plenty of signs that the young veteran's life could be in danger, yet no one intervened, or even kept a close watch.

That sadly happens too often. But this case is exceptionally distressing because of where it happened -- in a veterans hospital.

"Quality of care deficiencies" may have contributed to the patient's death at the U.S. Department of Veterans Affairs medical center in Philadelphia, according to a report released last week by the VA's inspector general.

The audit does not identify the veteran by name or gender or say where he or she was from. The center's patients typically come from four counties, including Bucks and Montgomery. Veterans from the Lehigh Valley also may seek treatment there for specific needs.

The inspector general was generous to use the term "care deficiencies." What happened to this veteran, as outlined in the report, was inexcusable.

Described as being in their mid-30s, the veteran entered the hospital with serious health problems, including an opioid addiction and a past kidney transplant. The vet went to the VA hospital after seeking help from an outpatient psychiatrist for the addiction. Ten days after being admitted, the patient was dead.

Hospital staff didn't monitor the patient for electrocardiogram changes despite a warning from the pharmacy that several of the veteran's 17 medications could cause abnormalities. Staff also didn't monitor for drug interactions including overlapping effects and toxicities, according to the inspector general's report.

There still may have been opportunities to prevent the death, if nurses had checked on the patient every 15 minutes as required. They didn't. In the patient's final hours, nurses checked only once, and by then it was too late.

Employees finally recognized the veteran needed help after being spotted unresponsive in the room, gasping and covered in vomit, their skin turning blue or purple.

The helpers who came struggled to provide life-saving care. Vital signs weren't available because the room's cardiac monitor wasn't working. There was no backboard or stretcher on the hospital unit.

The patient was moved to intensive care and died about two hours later. The medical examiner ruled the death was natural and caused by hypertensive cardiovascular disease.

The death occurred in late 2017. The inspector general opened a healthcare inspection "to evaluate quality of care and patient safety concerns" related to the patient and to the Philadelphia VA hospital's overall care in its acute behavorial health unit.

No other "adverse events" were discovered.

Regarding this patient's death, the inspector general found quality of care deficiencies; lack of communication among staff about the patient's condition; improper cardiac monitoring; inadequate response to a medical emergency; and inadequate patient observation.

In the 15 hours prior to the patient being found unresponsive, only 28 of 60 required rounds occurred, according to video surveillance. Hospital officials concluded the evening shift nursing staff falsified documentation.

"Staff were unaware of the patient's deteriorating medical condition, which contributed to missed opportunities to provide medical interventions that may have changed the outcome for this patient," the inspector general's report says.

It includes a timeline of the care the patient received on the day they died.

The veteran was hard to wake that morning. Video showed the patient leaving their room at 6:25 a.m. and walking unsteadily down the hall. Two nurses escorted the patient back to the room five minutes later.

The patient's blood pressure and heart rate were high. A psychiatrist instructed to withhold a scheduled methadone dose, given for the opioid addiction treatment, and another medication due to drowsiness. The instructions said to give the medication if the patient improved.

Ninety minutes later, another psychiatrist ordered the methadone to be given. That psychiatrist, who had just come on duty at a shift change, told the inspector general the patient was alert and oriented, with normal vital signs.

The inspector general noted that while blood pressure was normal, the patient's heart rate remained rapid. That should have prompted an electrocardiogram, as the patient would have been expected to have a normal or slower heart rate after being on methadone for four days.

When a patient starts methadone, death can occur from overdose or interaction with other drugs. The lack of communication and differing methadone orders "may have contributed to the patient's death," the inspector general said.

At 1:45 p.m., nurses wrote in a report that the patient didn't attend group sessions, didn't eat lunch and had been in bed most of the day. Another note at 7:32 p.m. said the patient appeared to be sleeping deeply, and numerous attempts to wake for meals and medications were unsuccessful.

At 8:50 p.m., the patient didn't wake despite a "deep sternal rub." At 9:07 p.m., staff called for the rapid response team. The patient was pronounced dead at 10:55 p.m.

The Philadelphia VA medical center -- formally known as the Corporal Michael J. Crescenz VA Medical Center -- concurred with nine recommendations from the inspector general. They included ensuring that staff understand the importance of monitoring for cardiac changes, drug interactions and signs of oversedation in methadone patients; communicating about complex patient care; and following patient observation policies.

The hospital said in its written response to the audit that it made those changes.

Morning Call columnist Paul Muschick can be reached at 610-820-6582 or paul.muschick@mcall.com

-- Philadelphia VA medical center

-- VA inspector general

-- VA hospital deficient care

-- Corporal Michael J. Crescenz VA Medical Center

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