Issue link: https://beckershealthcare.uberflip.com/i/981659
15 INFECTION CONTROL & PATIENT SAFETY VA OIG report: Buffalo VA staff failed to attempt resuscitation on dying patient By Megan Knowles T he Veterans Affairs Office of Inspector General evaluated the circumstances surrounding a patient's death in 2016 at the Buffalo (N.Y.) VA Medical Center and found the facility's nurses failed to try to resuscitate the patient, who was suffering cardiac arrest, according to a VA OIG report published March 12. e medical personnel pronounced the patient dead without attempting resuscitation, the report said. e report did not name the pa- tient, who died aer the incident, or when the incident occurred. A registered nurse and respiratory therapist at the facility "acted outside their scopes of practice and violated Veterans Health Administration and facility policy when they announced that the patient was dead, which influenced others not to take appropriate action," according to the report. e registered nurse did not want to attempt CPR, fearing it would crush the already frail patient's chest, according to the report. A different registered nurse failed to monitor the patient's heart rhythms and also le the desk where she monitored other patients' vital signs unattended, "thereby temporarily placing other monitored patients at risk," the report said. Hospital staff also failed to properly report the potential lapses in quality care to the patient's family in a timely manner. Additionally, the facility's leaders did not immediately remove the staffers involved in the incident from patient care duties pending the investigation's completion. In response to the incident, John Daigh Jr., MD, assistant VA inspector general for healthcare inspections, issued a series of recommendations to the Buffalo VA's facility director, such as ensuring hospital staff take part in mock drills to prepare for health emergencies, conducting a review to see if there are "issues undermining teamwork" at the facility and reviewing staff communica- tions with the late veteran's family. n PROFORMANCE ™ CLEANING VERIFICATION CLEARLY VISIBLE, EASY TO INTERPRET, OBJECTIVE TESTS OF CLEANING METHODS LUMCHECK ™ FLEXICHECK ™ TOSI ™ An independent check on the cleaning performance of pulse-flow lumen washers. For challenging the cleaning efficiency of endoscope washers with channel irriga on apparatus. Designed to provide a pass/fail detec on of cavita on energy within an ultrasonic bath. A blood soil device that directly correlates to the cleaning challenge of surgical instruments. HMARK.COM | 800.521.6224 SONOCHECK ™ FOR MORE INFORMATION ABOUT THESE AND OTHER INTELLIGENT SOLUTIONS FOR INSTRUMENT CARE & INFECTION CONTROL, VISIT HMARK.COM