Becker's Clinical Quality & Infection Control

26 PATIENT SAFETY & OUTCOMES Former nursing aide sentenced for 8 patient deaths at VA facility with 'serious, pervasive' issues By Gabrielle Masson R eta Mays, a former nursing assistant, was sentenced May 11 for murder and assault charges in the deaths of eight veterans at Clarksburg, W.Va.-based Louis A. Johnson VA Medical Center. Ms. Mays, 46, received seven consecutive life sentences, one for each murder, and an additional 240 months for an eighth victim, according to a news release from U.S. Attorney Randolph Bernard. In July 2020, the former nursing assistant pleaded guilty to seven counts of second-degree murder and one count of assault with intent to commit murder. Ms. Mays worked the night shi during the same period of time that the veterans in her care died of hypoglycemia. Ms. Mays has admitted to administering insulin to several patients with the intent to cause their deaths, though nursing assistants at the facility aren't authorized to administer medication. Ms. Mays must pay a total of $172,624.96 to the victims' families, the VA hospital, Medicare and insurance companies. "While responsibility for these heinous criminal acts lies with Reta Mays, an extensive healthcare inspection by our office found the facility had serious and pervasive clinical and adminis- trative failures that contributed to them going undetected," VA Inspector General Michael Missal said in the May 11 news release. is investigation, which began in June 2018, involved more than 300 interviews; the review of medical, phone, social media and comput- er records; consulting forensic experts and endocrinologists; the exhumation of some of the victims; and the review of hospital staff and visitor records to assess potential interactions. "e Department of Veterans Affairs and the Louis A. Johnson VA Medical Center grieves the loss of each of these Veterans and extends our deepest condolences to their families, loved ones and the Clarksburg community," Wesley Walls, a spokesperson for Louis A. Johnson VA Medical Center, said in an emailed statement to Becker's. "For the sake of all of West Virginia Veterans and their families, we are grateful for the independent OIG's investigation into this matter. What happened at the Louis A. Johnson VA Medical Center was heartbreaking, and we want to ensure veterans and families know we are determined to rebuild their trust. "While this matter involving an isolated em- ployee does not represent the quality health- care tens of thousands of North Central West Virginia Veterans have come to expect from our facility, it has prompted a number of improve- ments that will strengthen our continuity of care and prevent similar issues from happening in the future. Also, while we cannot bring back loved ones lost, VA has reached financial settle- ments with over a half dozen families of veteran victims via the Federal Tort Claims Act. "e VA OIG Report focuses on events that oc- curred from July 2017 to June 2018. During the OIG investigation, VA put in place safeguards to enhance patient safety, including medical chart audits, checks and balances within phar- macy quality assurance processes and quality management reviews. "e Louis A. Johnson VA Medical Center has started implementing each of the OIG's recommendations, which are expected to be completed by March 31, 2022." Mr. Walls included numerous other initiatives the facility has already implemented, including patient care, education, standardization and tracking, leadership and culture, and overall enterprise processes improvements. n Cleveland Clinic researchers identify link between COVID-19, Alzheimer's-like brain impairment By Erica Carbajal W hile neurological problems have been a common symptom among COVID-19 long-haulers, the underlying mechanisms for this have remained largely unknown. A study led by Cleveland Clinic research- ers may have a glimpse at the answer. The research, published June 9 in Alzheimer's Research & Therapy, leveraged artificial intelligence to compare existing datasets between patients with COVID-19 and Alzheimer's. While researchers did not find evidence the virus directly infects the brain, they did find close network-based rela- tionships between SARS-CoV-2 and genes/proteins asso- ciated with Alzheimer's, as well as several other neurolog- ical diseases. They then evaluated potential links between COVID-19 and two hallmarks of Alzheimer's: neuroinflam- mation and brain microvascular injury. "We discovered that SARS-CoV-2 infection significantly al- tered Alzheimer's markers implicated in brian inflammation and that certain viral entry factors are highly expressed in cells in the blood-brain barrier," said Feixiong Cheng, PhD, lead study author and assistant staff at Cleveland Clinic's Genomic Medicine Institute. "These findings indicate that the virus may impact several genes or pathways involved in neuroinflam- mation and brain microvascular injury, which could lead to Alzheimer's disease-like cognitive impairment." Dr. Cheng and team are now conducting research aimed at identifying measurable biomarkers and potential new thera- peutic targets for COVID-19-related neurological issues. "Identifying how COVID-19 and neurological problems are linked will be critical for developing effective preventive and therapeutic strategies to address the surge in neuro- cognitive impairments that we expect to see in the future," Dr. Cheng said. n

• Cover