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Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.
Louis Calderon:
Hello listeners. This month we are publishing an “In Case You Missed It” episode of our Veteran Oversight Now podcast. We’re reaching back and republishing one of our most listened to episodes from April 2024, which covered a veteran’s death, following a Code Blue Alert delay at the Memphis VA Medical Center. This episode includes a conversation about the incident and dives into the associated VA OIG report. Check out our website vaoig.gov for all previously published podcast episodes or find us anywhere you normally listen to podcasts. Be sure to subscribe, and thanks for listening.
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 Healthcare Inspections. Trina is a board-certified physician 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 Lt. Col. 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, as you pointed out, and supports 10 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 healthcare-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 Healthcare Inspections 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 to worsen, that’s when they noted the need for ICU care.
Fred Baker:
That’s when, I say, eventually it came to a point where they couldn’t take him off of the BiPAP, correct?
Trina Rollins:
They couldn’t 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 was overtaking the situation. The infection was winning. And so the patient started having difficulty with their breathing. And then when the breathing’s 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 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 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?
Trina Rollins:
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, this occurred in the middle of the night, early morning hours at Memphis. So you can imagine that there’s limited staff there 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:
So, even though it was in the middle of the night and 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.
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, 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 tech noticed but didn’t follow protocol. Instead, the tech tried to call the nurse to determine if the patient was unconscious, or 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 it wouldn’t be their role to get up and walk to the patient’s room to find out, right?
Trina Rollins:
No. No, not at all.
Fred Baker:
So they’re watching this bank and they’re seeing the monitor. They attempt to call and find out what’s causing 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 tech tried a couple of different times to reach nurse and 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 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 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 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 tech 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 five minutes later, the call was made and they did respond to the patient, 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 very 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:
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 analyses 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 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 were 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 a 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 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 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 mentioned in this podcast, you can submit a complaint to the OIG by phone, 1-800-488-8244, or you can go to our website, www.vaoig.gov/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 Veterans 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 OIG continued its oversight of VA’s programs and services during the final month of summer. Eight OIG investigations had significant developments in August. Here are some highlights.
A healthcare professional at the Orlando VA Medical Center installed a hidden camera in multiple unisex bathrooms at the facility to secretly record employees without their consent. The defendant was sentenced to 24 months’ imprisonment, 48 months’ supervised release, and was ordered to participate in sex offender treatment after pleading guilty to video voyeurism. The defendant was previously suspended indefinitely by the facility pending the completion of this investigation and criminal proceedings.
A multiagency investigation revealed that a veteran submitted false documents to VA to obtain a VA-backed loan for a property valued at $2.1 million. The investigation also revealed that the defendant used his position as an Army financial counselor to target Gold Star families to invest their survivor benefits in investment accounts that were managed by his private employer. The defendant was sentenced in the District of New Jersey to 151 months’ imprisonment, 36 months’ supervised release, and forfeiture of $1.4 million. They previously pleaded guilty to wire fraud, securities fraud, making false statements in a loan application, committing acts furthering a personal financial interest, and making false statements to a federal agency. Restitution will be determined on a later date.
The last case I’ll mention involves a chemical and laboratory supply company that reached a settlement agreement resolving allegations that it fraudulently overcharged federal agencies for goods purchased between 2008 and 2017. Through its federal procurement contracts, the defendant agreed to offer or provide government purchasers the same or better prices than were offered to a private-sector customer. The defendant allegedly violated the False Claims Act by not offering or providing federal government purchasers the most favored customer pricing, as stipulated by the contract. The company will pay $5 million to the federal government, of which over $2.2 million is restitution. Of this amount, VA will receive over $144,000.
Read more about the latest OIG investigative updates in the August monthly highlights, which can be found under the Reports tab on our website.
Now turning to reports, we issued 15 reports in August.
According to a report by the OIG’s Office of Audits and Evaluations, Ineffective Oversight of Community Care Providers’ Special-Authorization Drug Prescribing Increased Pharmacy Workload and Veteran Wait Times, VHA purchases community health care by contracting with third-party administrators, which contract with community providers. Community providers’ prescription requests must be filled at VA pharmacies and must consider VA’s approved drugs before other drugs that require special authorization. This audit found that community providers rarely submitted required justifications with the initial prescriptions, leading to about $200.2 million in questioned costs. Staffing challenges and increased community care prescriptions caused a backlog, with community care prescription processing averaging 11 days, which exceeds VHA’s four-day standard. VHA did not hold third-party administrators accountable for ensuring community providers followed procedures, and less than 2 percent of community providers completed the relevant training. The OIG made seven recommendations to improve community providers’ compliance when prescribing special-authorization drugs.
Meanwhile, the OIG’s Office of Healthcare Inspections reviewed preparation by the Veterans Crisis Line—also known as VCL—for implementation of the National Suicide Prevention Hotline three-digit dialing code “9-8-8 press 1.” The OIG determined VCL leaders hired additional frontline staff in anticipation of the call volume increase, but they had not increased the number of supervisors to meet the previously established supervisor-to-staff ratio. The OIG also identified a concern related to frontline staff’s awareness of and feelings of support from supervisors to use postvention resources. VCL staff would benefit from awareness and training regarding the use of these resources. The OIG found VCL leaders, in conjunction with the Office of Information and Technology leaders, assessed, planned for, and implemented technology changes related to “988 press 1.” Additionally, quality metrics data was reported monthly to VCL leaders at executive leadership committee meetings and reflected quality oversight. The OIG made two recommendations to the VCL director.
Other reports we published in August include a Care in the Community inspection of the VA MidSouth Healthcare Network and three Vet Center Inspection Program reports that focused on Continental District 4 and vet centers in 10 states.
Thank you for listening to this summary of the OIG’s recent work. You can read the full August monthly highlights on our website at www.vaoig.gov.
Stephanie Beres
Fred Baker is a retired Army veteran and a career journalist. He has worked in government public affairs for the Army, the Department of Defense, and the VA Office of Inspector General.
Lauren O’Connor is a career writer-editor with the federal government. Here at the VA Office of Inspector General, she works to help veterans like her father, who graduated from the US Naval Academy and served on submarines before teaching at the Naval War College in Newport, Rhode Island.
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 at vaoig.gov or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 988, press 1, and speak with a qualified responder now.