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Healthcare Inspection Questionable Cause of Death VA Puget Sound Health Care System Seattle, Washington
Report Number 08-02620-22, 11/12/2008 | Full Report (PDF)
The purpose of the review was to determine the validity of allegations that: (a) the complainant’s husband’s death was caused by equipment failure and not aspiration pneumonia, (b) staff did not communicate to the complainant that her husband choked and had to be suctioned prior to his death, and (c) the physician did not accurately annotate the cause of death (COD). We concluded that equipment failure occurred but could not determine whether this was a contributing factor in the patient’s death. We found that community living center (CLC) staff did not inform the complainant that her husband aspirated and had to be suctioned shortly before his death. We concluded that CLC staff should have filed an incident report and documented clinical disclosure. Although the death certificate accurately listed the COD, we concluded that the clinician did not ensure that the complainant fully understood. We also concluded that agency staff competencies were not validated for the long-term care patient population. We recommended that: CLC nurse managers clarify suction equipment procedures, assess staff competency with equipment, and conduct equipment checks. CLC staff comply with the requirements related to incident reporting and disclosure. Clinicians explain medical conditions in simple terms and elicit verbal understanding from the patient and/or family. Managers validate agency staff competencies related to CLC patients.