ANN ARBOR, MI – A patient at Ann Arbor’s Veterans Affairs hospital died last year after a nurse mistakenly led others to believe the patient had a do-not-resuscitate order, a federal report revealed Tuesday, Nov. 7.Now, the nurse could face discipline up to dismissal related to the 66-year-old’s December 2016 death, Brian Hayes, public affairs officer for the VA Ann Arbor Healthcare System said Wednesday.”These are serious allegations, and we are looking immediately into taking appropriate personnel actions against those named in the report,” according to a statement released by the Ann Arbor VA. “Secretary (David) Shulkin has made clear that VA will hold employees accountable when they fail to live up to the high standards taxpayers expect from us. And that’s exactly what we’re doing in this case.”The nurse confused another patient’s do-not-resuscitate order with the patient who died and other staff members relied on this belief, according to the report by the Office of the Inspector General for the Department of Veterans Affairs.The system also had inadequate measures to make all staff aware of resuscitation status, despite policy requirements, according to the report.Michigan reps ‘deeply disturbed’ by Detroit VA hospital’s poor ratingTwo U.S. Representatives from Michigan want answers from Veterans Affairs Secretary Robert McDonald following press reports that the Detroit VA Medical Center has been rated a one-star facility (out of five possible stars) by a formerly-secret internal rating system.”This event was particularly disturbing as about a year prior to this event, system leaders identified a vulnerability in the process of confirming resuscitation status, especially during situations when a patient’s medical status was deteriorating,” the report stated. “… Although system managers assessed the concern, they failed to identify a solution due to difficulties in balancing patient safety and privacy concerns, and no actions were taken to decrease this risk.”The patient was noted to have conditions including cancer, diabetes and chest pain when he saw his primary care physician in fall 2016, according to the report.  He later, after transfer from a non-VA facility, had surgery to bypass a blocked artery believed to be causing right leg numbness and pain.Minutes before he died, the patient had chest pain and an elevated troponin – a lab test to indicate a heart attack – and eventually vomited and became unresponsive with abnormal breathing, the report showed.The inspector’s report noted that it’s not clear resuscitation efforts would have been successful.The Office of the Inspector General was notified of the incident on Dec. 26, 2016.The nurse had been removed from direct patient care prior to the inspector’s report being issued Tuesday and Hayes said the Ann Arbor VA can now take further action against the nurse with the report completed.He said though additional action had not been taken as of Wednesday morning, it would be taken “immediately.”No other personnel face review for discipline, he said.The nurse involved in the death previously faced administrative action for incidents that occurred in 2012 and 2015, according to the federal report.The day of the death, the nurse was assigned three patients, one of which had a DNR status, according to the report. He told investigators the resuscitation statuses were noted at the start of the shift and he relied on memory and did not recheck the resuscitation status of the patient during the event.In addition, staff answers varied on how a patient’s resuscitation status was determined and how the information was communicated to one another in general, according to the report.”The system had no environmental cues or formalized processes in place for (the nurse), or other staff, to identify the correct information and avoid a memory-based error,” the report stated.Both the report and Hayes noted that issues with confusion regarding a patient’s resuscitation status is not unique to the VA, however the Ann Arbor VA has taken a number of steps to address the issue since the 2016 death.Two days after the incident, a new process was established that requires a patient roster to be printed, and resuscitation status to be identified and initialed by two nurses, according to the report. The nurse supervisor also reviews this process each shift, and the document is kept accessible for review if a code is issued.In addition, Hayes said code status is now placed at the top of each patient’s chart, so its easily visible. He also said teams now conduct frequent mock code drills and charge nurses lead daily safety huddles in which code statuses are reviewed.”Now, we require a two-person verification code status and, in a hand-off situation in shifts with nurses, they go over code status and make sure its confirmed and done in a templated process, so that its habitual and they go through every patients’ code status in the floor,” he said. Veterans to tell their ‘Stories

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