PHOENIX — The Phoenix VA Health Care System demonstrated a "deficient" response when a patient experienced an emergency and waited up to 11 minutes before receiving basic care, according to the inspector general.
A report released Wednesday from the U.S. Department of Veteran Affairs Office of Inspector General criticizes how the Phoenix VA responded to a patient who experienced a medical emergency outside the entrance of a VA facility and subsequently died. The patient didn't receive care until the Phoenix Fire Department arrived at the scene and transported the patient to a community hospital, where the individual died a couple of days later.
The OIG "identified deficiencies in the initiation of the patient’s emergency medical care, the quality of the patient’s care prior to the medical emergency, and completion of comprehensive quality reviews," the report states.
The new report comes a decade after the Phoenix VA was at the center of a national scandal that exposed how veterans were dying as they waited for medical care. Advocates are continuing to pressure Congress to address lingering issues in the VA system.
The latest OIG report probing the patient's 2023 death in Arizona highlights how officials are continuing to find problems in the Phoenix VA's policies.
After the release of the new report, Arizona’s entire congressional delegation is demanding answers from the man in charge of the Department of Veterans Affairs.
In a letter signed by Arizona lawmakers on Friday, members want Secretary Denis McDonough to provide specific answers on the protocols that allowed the incident to happen, and how the VA plans to implement 10 recommendations outlined in the OIG report on the March 2023 incident at the Carl Hayden VA Medical Center in Phoenix.
“The investigation shouldn’t stop just there,” says Darin Selnick with Concerned Veterans of America. “The VA should not only be doing an investigation in Phoenix, but there should be an investigation of the entire system from top to bottom to see where else this could be a problem before it happens again, he adds.
According to the report, the patient had visited the Phoenix VA facility that day for a urology appointment. As the patient was leaving, they passed out in the parking lot and a family member moved their vehicle to outside the facility's entrance and went back inside for help.
An employee called 911 and attempted to request a rapid response, which is a "safety net" the facility provides to patients on-site when their condition suddenly deteriorates. But the rapid response was not initiated and the VA police were not called.
Because the patient was technically outside the building, calling for a rapid response was considered "not the correct procedure."
"The OIG is concerned that facility policy does not align with VHA requirements to 'optimize patient safety for those requiring resuscitation' and ensure 'emergency response capability to manage cardiac arrests on VHA property,'" the OIG report states.
The OIG concluded that "conflicting" policies, a lack of staff trained in CPR and limited access to defibrillators may have all been factors contributing to the patient's delayed care.
The investigation further found faults with how the patient received care from the Phoenix VA in the time leading up to the patient's death. A cardiologist allegedly did not order a cardioverter defibrillator for the patient, despite documenting the treatment in the patient's plan of care. No vital signs were taken for the patient during their medical appointment prior to the patient's emergency.
"The OIG is unable to determine whether the assessment of vital signs would have indicated the patient’s impending clinical deterioration," the report states. "However, not assessing vital signs may have contributed to a missed opportunity for early identification of the patient’s clinical decline."
Despite the issues found with the patient's emergency care, the OIG was "unable to determine whether a change in care would have resulted in a different outcome for the patient."
Following the review, the OIG made 10 recommendations for policy improvements and the Phoenix VA has submitted action plans to implement the recommendations.
U.S. Rep. Ruben Gallego, D-Arizona, sent a letter Wednesday to the VA asking for more answers on issues documented in the recent OIG report.
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