Healthcare Inspection Quality of Care in the Intensive Care Unit VA Northern Indiana Health Care System Fort Wayne, Indiana

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding the quality of care for four patients at the VA Northern Indiana Health Care System (the facility), Fort Wayne, IN. We found inadequate management, documentation, and review of Patient 1’s cardiopulmonary arrest and inadequate Intensive Care Unit (ICU) monitoring of Patient 2. We also found that Patient 3 should not have been accepted in transfer from a community hospital. We identified no quality of care issues in the care of Patient 4. Additionally, we found that during a 6-month period, there were 23 days with time periods ranging from 4 to 15 hours during which there were no staff in the facility with demonstrated competence in out-of-operating room (OR) airway management. We found that Medical Officers of the Day were routinely providing care to patients in the emergency department and to inpatients, including the ICU, contrary to Veterans Health Administration (VHA) policy. We did not substantiate that the physician was responsible for patient deaths, delayed transfer of Patient 1, inappropriately prescribed a medication for Patient 2, or prematurely removed Patient 3 from a ventilator. We substantiated that there were two intervals when three patients in the ICU received mechanical ventilator therapy concurrently. We did not substantiate that there were not backup ventilators in the facility or that the use of three ventilators simultaneously was in violation of facility policy. We recommended that the System Director: ensure that peer review assessments of the care issues identified for Patients 1–3 are conducted and that action is taken as necessary, confer with Regional Counsel regarding adverse event disclosure to the family of Patient 1, ensure that care provided in response to cardiopulmonary arrests is documented and reviewed in accordance with facility policy, ensure that staff with demonstrated competence and clinical privileges or scope of practice are available at all times to provide out-of-OR airway management, and ensure that ICU physician coverage complies with VHA policy. The VISN and System Directors concurred with the inspection results. We will follow-up on the planned actions until they are complete.