
The damning OIG report comes just weeks after VA admitted that six veteran deaths were linked to delayed cancer screenings at a VA facility in South Carolina and a report that appointment delays led to veterans being harmed in Augusta, Ga. VA, which spent more than $3.5 million on furniture on the last day of fiscal year 2013, also awarded a five-figure bonus to the executive who oversaw the Memphis facility, even as it acknowledged that problems were cropping up.
Memphis VA Medical Center saw three patient deaths in its emergency department that prompted an anonymous phone call to the OIG in October 2012.
In January 2013, the OIG found that “Facility response [to the deaths] considered inadequate” and a review was initiated with a May 29-31 site visit.
“We substantiated that a patient was administered a medication in spite of a documented drug allergy, and had a fatal reaction. Another patient was found unresponsive after being administered multiple sedating medications. A third patient had a critically high blood pressure that was not managed aggressively, and experienced bleeding in the brain approximately 5 hours after presenting to the ED,” according to the OIG report’s conclusions.
“We found that the facility took actions as required by VHA [Veterans Health Administration] in response to the unexpected patient deaths, but noted that implementation of action plans developed through RCAs was delayed and incomplete. We found inadequate monitoring capabilities for patients in some ED rooms, an issue identified during our site visit last year. We also found that nursing ED-specific competency assessments had not been completed,” according to the report’s conclusions.
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