An erroneous wristband placed on a 65-year-old Vietnam veteran caused a “delay in life-saving intervention” at the Mather VA facility in Sacramento, federal investigators say in a new report prompted by the patient’s death under questionable circumstances last October.
The wristband incorrectly identified patient Roland Mayo as having given a “Do Not Resuscitate” order, also known as a DNR.
Facility staff did not follow through on the patient’s request upon admission to discuss advance directives. We found no evidence of advance care planning discussion during the patient’s hospital stay.
Department of Veterans Affairs Office of Inspector General.
The resulting “confusion” about Mayo’s status “delayed chest compressions, defibrillation pad placement, and medications” when he went into cardiac arrest, investigators with the Department of Veterans Affairs Office of Inspector General concluded. As a result, two precious minutes reportedly passed between the time Mayo’s pulse stopped and CPR began.
“The American Heart Association recommends initiating immediate chest compressions for adults suffering from sudden cardiopulmonary arrest,” investigators noted.
They further described a seemingly frantic scene on the day of Mayo’s death, during which so many medical personnel crowded into the patient’s room that they blocked the doorway and spilled out into the hallway.
“A nursing supervisor and physician requested several times for nonessential personnel to leave, but no one did so,” investigators noted. “Staff reported having difficulties hearing the physician’s orders throughout the code because there were so many people in the room.”
At one point, investigators added, an anesthesiologist showed up and asked if any assistance was needed. Told, incorrectly, that Mayo had a DNR order, the anesthesiologist left. She was about 50 steps away when she heard a second “code blue” announced over the loudspeaker and she returned to Mayo’s room, investigators recounted.
The congressman who requested the inquiry into Mayo’s death, Rep. Ami Bera, D-Calif., said he was “extremely troubled” by the findings. Bera, who is a medical doctor, called on the VA to implement corrective actions nationwide.
“I know that every second counts in an emergency,” Bera declared.
Sacramento-based attorney J.R. Parker, who is representing Mayo’s three children in a federal lawsuit filed last month, said in an interview that the report “is performing a really important service” by shedding light on what happened.
In their official response, VA officials say they have developed “a very robust process to ensure systems are in place to correct all of the findings” identified in the report. New policies have been put in place and additional training has been provided, officials say. The patient wristbands have also been redesigned.
Tara Ricks, spokeswoman for the VA’s Northern California Health Care System, added in a statement Thursday that the agency “welcomes more opportunities to further evaluate our procedures and identify areas for improvement.”
“We are deeply dedicated to the health and safety of our patients and will continue to take swift and corrective actions to address the identified items in the OIG report,” Ricks added.
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The 180-bed Mather facility is part of the VA’s Sierra Pacific Network, also known as the Veterans Integrated Service Network 21. The sprawling network provides medical services to veterans throughout northern Nevada, northern and central California and Hawaii.
A Citrus Heights, Calif., resident, Mayo had served in the Army’s 101st Airborne Division and worked as a Riverside County deputy sheriff. He had a medical history that included hypertension and post-traumatic stress disorder when he entered the hospital for elective heart surgery.
Mayo did not have a DNR or other advanced health-care directive when he was admitted, though he told hospital officials he would “would like to discuss” the issue. Nonetheless, investigators found, Mather officials “did not follow through on the patient’s request.”
The patient wristband provided Mayo included several pieces of information that were incorrect, such as that he was at risk for choking or for wandering off, in addition to the incorrect statement that he had a DNR, investigators found. They did not determine whether the errors were due to a clerical mistake or a software glitch.
On Mayo’s ninth day in the hospital, he cried out while in the bathroom. A nurse found him lying on the floor, breathing and with a pulse. Then, investigators recounted, Mayo vomited and became limp and unresponsive.
The most skilled person to perform intubation was the anesthesiologist; however, she was dismissed after being told that the patient was DNR.
Department of Veterans Affairs Office of Inspector General.
Lifted onto his bed, Mayo continued vomiting while hospital staff tried to suction his airway.
“We were informed by staff at the bedside multiple times that the patient was DNR/DNI and the patient had a wrist band to support this,” the lead physician subsequently reported. “After (about) 3-4 minutes we were later told his code status was unclear.”
Mayo’s pulse reportedly stopped three minutes after the “code blue” was first called. At the five minute mark, investigators say, “a staff member concluded that there was no DNR/DNI order in the computer” and the full array of CPR and defibrillation techniques were tried, to no avail.
Investigators attributed Mayo’s death to “aspiration of gastric contents into the lungs.” Rapid control of the airway, typically through intubation, is the way to avoid this, investigators noted.
Michael Doyle: 202-383-0006, @MichaelDoyle10