8 Aug 8th-Aug 14th, 2024 phoenixnewtimes.com PHOENIX NEW TIMES | NEWS | FEATURE | FOOD & DRINK | ARTS & CULTURE | MUSIC | CONCERTS | CANNABIS | to the veteran’s family member can be seen parked directly in front of the entrance to the Ambulatory Care Clinic, visible from the information desk through the clinic’s ceiling-high glass windows. According to the hospital’s policies, however, it was about as close as it could be without being close enough. According to the OIG report, the hospi- tal’s policy was that its rapid response team respond to medical emergencies inside any of the facility’s buildings. If emergencies happen outside but still on facility grounds — like in the parking lot or the parking garage — employees are instructed to call 911 and the VA police. The hospitality employee who initially called for the rapid response team knew that policy, the OIG report said, but requested one anyway. “I was just trying to get someone there fastest,” the employee told OIG investigators. The employee added, “I understand it’s outside, but it’s really three feet from the front door.” The report added that the hospital’s chief of medicine service and specialty care, the chief of the emergency depart- ment and the chair of the cardiopulmonary resuscitation committee all “expressed concerns to the OIG that the lack of timely (basic life support) may have contributed to the patient’s death.” “That is right in front of our Ambulatory Care Clinic,” one of the three hospital leaders told investigators, though the report doesn’t specify which. “I think that’s within our rapid response team to react.” The report stated that the OIG “is concerned that facility policy does not align with VHA requirements to ‘optimize patient safety for those requiring resuscita- tion’ and ensure ‘emergency response capability to manage cardiac arrests on VHA property.’” Additionally, the report noted that there were no automated external defi- brillators in the lobby of the clinic, nor had non-medical hospital employees been offered CPR training as required by VA policy. As a result, no one was able to perform life-saving treatment until the fire department responded. In the interim, however, there was one extra indignity. According to the report, while the unconscious veteran and the family member waited for emergency personnel, a hospital volunteer asked the family member to move their car “three different times.” ‘They deserve far better’ In its report, the OIG made 10 recommen- dations to the hospital. They included altering the policy governing when a rapid response team is called, offering CPR training to nonmedical personnel, adding additional defibrillators and assessing staff training regarding the use of the Joint Patient Safety Reporting System. Bryan C. Matthews, the facility’s Medical Center Director, concurred with all 10 recommendations. “I would like to thank the OIG for their thorough review of this case and recom- mendations on process improvements,” Matthews wrote in an email included in the OIG report. “Phoenix VA Health Care System appreciates the opportunity to partner with the OIG on our high reli- ability journey. We remain steadfast in our commitment to zero harm.” The saga may not be over, however. In his letter to the Under Secretary of Health, Gallego demanded answers to 10 questions about the failures identified in the report. He also requested a meeting with local VA leadership and regular briefings on how the hospital is implementing the OIG’s recommendations. “It is our duty to care for our veterans,” Gallego wrote, “and they deserve far better than what today’s report indicates.” Carl T. Hayden Veterans Administration Medical Center is located within the district of U.S. Rep. Ruben Gallego, who criticized the hospital after the OIG report was published. (Photo by Elias Weiss) Dying at the Door from p 6
