East Orange, NJ Veterans Affairs Hospital VA

   2003

...Although we concluded that the complainant received appropriate medical care, we identified some lapses in documentation of important clinical information...

Although we did not substantiate the allegations, we noted some documentation lapses during our medical record review. For example, during the 4 days the complainant was on ward 2D, we found only two notes addressing pressure ulcer care. In the SICU, we found blank spaces in the hard copy medication administration documents; thus, it was unclear whether SlCU nurses administered some medications. Although nursing employees noted and treated the complainant's skin breakdown early in his SlCU stay and documented this care in the April 24 transfer note to ward 2D, the Impaired Tissue Integrity section of the SlCU flow sheet was blank on 19 of 20 days. The physician's discharge instructions did not address pressure ulcer care. However, the complainant confirmed that on the day of discharge, the physician provided minimal instructions to ". ..continue to use the salve." Finally, the June 13 discharge summary did not discuss any pressure ulcers being identified or treated during the hospitalization....

East Orange, NJ VA Patient Care & Infection Control VA OIG Report 2003

An anonymous complainant alleged that a patient died from overmedication. On December 21, 1997, at approximately 6:20 a.m., a nursing assistant (NA) on Ward 128, a locked acute psychiatry ward, found the patient lying in his bed without pulse or respiration. The NJHS "Code Blue" Team performed unsuccessful cardio-pulmonary resuscitation (CPR). The complainant alleged that a second patient, on Ward 6A, a 16-bed cardiac care ward, died as a result of employees' misconduct, when they left the telemetry monitoring room unattended and failed to assess the patient every 30 minutes. On January 13, 2001, at approximately 11:55 p.m., the midnight shift charge nurse found the second patient unresponsive and lying on the floor of his room. The "Code Blue" Team performed CPR on the patient without success. Both of these patients had reportedly been assessed as alert and medically stable before their deaths.

....Conclusions:

Ward employees' care and monitoring of the patient could have been improved. Employees did not check the patient's personal belongings for contraband; nurses did not take, or did not record the patient's vital signs at 10:OO p.m., on December 20; and nursing employees did not conduct, or did not record 545 a.m. or 6:00 a.m. suicide prevention checks on December 21.

....nurses did not follow NJHS policy for assessing the patient and the telemetry technician on duty the evening of the patient's death did not appropriately monitor the patient 25 minutes before and 15 minutes after he developed cardiac arrest...

...An 11:40 p.m. ECG rhythm strip shows that the patient developed ventricular fibrillation- which no nursing employees detected. At approximately 11:55 p.m., the night shift charge nurse found him unresponsive, without pulse or respirations. She stayed with the patient while other employees summoned the "Code Blue" Team. She and other ward employees were unable to immediately start resuscitative efforts because the 427-pound patient was lying face down with his body wedged in the bathroom doorway. The "Code Blue" Team attempted resuscitation, but the patient was pronounced dead at 12:30 a.m., on January 14....

    ...The week following the incident, the NJHS Associate Director for Patient Care Services (ADPCS), who was responsible for NJHS nursing employees, reviewed the incident. Human Resources Management employees assisted the ADPCS because of the possibility that the Director might have to approve employee disciplinary actions.

    The week following the incident, the NJHS Associate Director for Patient Care Services (ADPCS), who was responsible for NJHS nursing employees, reviewed the incident. Human Resources Management employees assisted the ADPCS because of the possibility that the Director might have to approve employee disciplinary actions.

    The ADPCS concluded that the SlCU nurse who was reassigned to the ward did not check on the patient after 11:15 p.m.. even though he was her onlv ~atient. He The ADPCS ilso concluded that the telem erage of the telemetry roo The ADPCS IbJLd concluded that incident was the acting charge nurse. ke she had not ensured that someone monitor the-telemetry screens when she that the telemetry technician left the telemetry room unattended, and she failed to ensure that a nurse checked the patient every 30 minutes.

    The ADPCS told inspectors that the quality of care issues during his January 2001 review centered on the technician's and nurses' failures to monitor and assess the patient. We found several statements by various involved ADPCS did not complete a summary report documenting his overall findings and conclusions.

    After the ADPCS concluded his review, the acting evening shift charge nurse wrote to NJHS managers, in April 2001 and July 2001, -[bl@ asserted not only that the ADPCS' review conclusions and but also that there were unexplored systems problems related to the incident. A union official's May 2001 letter to NJHS managers on the three employees' behalf, also outlined the issues. One of the issues raised speculation that the patient's telemetry alarm might not have functioned properly or it might have been turned off during the time he developed cardiac arrest. Both RN's were only four doors away in the medication room at the time, and should have, but did not hear any alarms. Two other issues cited in the letters were: the inadequacy of beds and wheel chairs on the telemetry ward to safely and comfortably accommodate large patients, and the inadequacy of some telemetry ward patient rooms, particularly this patient's room, to allow exceptionally large patients to safely ambulate and to receive effective emergency treatment on time. We did not find any indications during our interviews and review of documents that NJHS managers had addressed these issues. Conclusions: We concurred with the ADPCS' review findings that the nurses and telemetry technician did not carry out their assigned patient care responsibilities as required by NJHS policy. We concluded that the lapses in the nurses' and the technician's professional behaviors in monitoring the patient were partially influenced by circumstances which occurred during the shift. These circumstances included the The ADPCS should have written a complete report of his review. Furthermore, NJHS managers should have addressed the systemic issues brought to their attention by the acting charge nurse and the union official.

1993 GAO Study into TB Out Break at East Orange New Jersey

Department of Veterans Affairs Hospital

Fifty-one patients hospitalized at VA'S East Orange Medical Center between

January 1990 and May 1992 had tuberculosis. Of these, 13 met the

definition of multiple drug resistant tuberculosis as specified by the

Centers for Disease Control and Prevention (CDC). AU 13 of the patients

were infected with m; 11 of them died-an 85-percent mortality rate. In

addition, CDC found that in the infectious disease ward, 5 of 10 employees

who previously tested negative for tuberculosis in 1991 tested positive in

1992, indicating exposure to active tuberculosis disease. CDC referred to

the situation at East Orange as an outbreak.

GAO obtained data on five independent investigations of the outbreak at

the East Orange Medical Center and interviewed key officials of the

investigating agencies to discuss factors contributing to the outbreak. GAD

also interviewed VA officials to discuss their plans to address the problems

and their actions to assist other centers at potential risk. GAO conducted

site visits to the East Orange Medical Center to follow up on actions taken

as a result of previous audit recommendations and also to CM: to discuss

the tuberculosis problem in a national context. GAO analyzed

Results in Brief

Lax infection-control practices and inadequate isolation rooms were

problems associated with the outbreak of tuberculosis at the East Orange

Medical Center. Medical center staff did not consistently use appropriate

Further, until spring 1991, no analysis or evaluation of the tuberculosis

cases had been done that would have revealed patterns and trends in the

spread of the disease. The center did not have a comprehensive

employee-testing program to monitor the staffs exposure to active

tuberculosis disease. Isolation rooms did not have proper airflow, and air

exhausted from these rooms may have contaminated other areas of the

medical center. In addition, certain high-risk areas of the medical center,

such as the ambulatory care and intensive care units, lacked proper

1993 GAO Report on TB Outbreak at East Orange, New Jersey VA Hospital

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 editor@VA Malpractice.Info

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