A patient at a California Veterans Affairs hospital died after nurses incorrectly put a “do not resuscitate” wristband on him, according to a federal watchdog.
Nurses at a VA Northern California Health Care System facility in Mather, California, used a wristband with the wrong treatment code, which contributing to the death of the elderly veteran, the VA Office of Inspector General said in a report requested by Rep. Ami Bera, D-Calif., and released Tuesday.
“We substantiated that the patient’s wristband had the incorrect code status of Do Not Resuscitate/Do not Intubate printed on it and that staff did not verify the wristband code status during the patient’s nine-day hospital stay,” the IG said. “We substantiated that the incorrect code status on the patient’s wristband led to a delay in life-saving intervention.”
Incorrectly labeling the patient with a DNR wristband delayed chest compressions, defibrillation pads, and medications. The IG described a confusing scene when the man died, with nursing staff unsure whether they should resuscitate him, and the man lying on his side, with “no efforts to revive the patient,” as the anesthesiologist said in the report.
The IG said hospital employees had been working to improve patient code labeling, but the needed changes weren’t made in time to prevent the man’s death. The man, admitted for an elective bypass surgery, developed complications and died nine days later.
This isn’t the first time the IG faulted the California VA system for dangerous practices.
A December 2014 report criticized the hospital system’s patient records didn’t indicate if clinicians educated stroke patients or their care-givers about strokes. The California system also ranks in the lowest quintile of VA hospitals nationally for the number of patient complications and wait times for speciality care.
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