AUGUSTA—A patient at the Charlie Norwood VA Medical Center in Augusta, GA, was held in restraints for nearly three days, contributing to the blood clots in his legs that resulted in his death, a VA inspector general report found last month.

The report outlines numerous failures by the veteran’s healthcare team and provides a worst-case example of gaps in mental health treatment and the improper mitigation of psychiatric symptoms.

The patient, a man in his 60s who goes unnamed in the report, had a long history of treatment at the Augusta VAMC. Suffering from schizophrenia, COPD, chronic pain, as well as other conditions, he’d been seeking care at the facility since the 1990s. For more than 15 years he had been prescribed antipsychotic injectable medication and daily oral medications to treat his mental illness.

His disruptive behavior was also well known, and in 2015 facility staff assigned the patient a Category 1 behavioral patient record flag due to disruptive behavior and threatening language toward staff.

In spring 2019, the patient appeared at one of the hospital’s clinics requesting his injectable medication. Described by staff as irritable but cooperative and logical, he was told he was not due for another 24 days and sent away. The next day he appeared at a clinic for homeless veterans very agitated and in a state of disarray. The staff called police and a code gray—a call for assistance for a behavioral emergency—was initiated. The veteran was transported to the emergency department where providers found his blood sodium level was low. He was then admitted to the VAMC’s inpatient medical unit for treatment of hyponatremia.

The patient, a tobacco user, said he wanted to smoke. When he was told he couldn’t, he became disruptive, threatening a resident physician. Staff initiated a second code gray and the patient was placed in four-point restraints while nursing staff administered three intramuscular sedatives.

On that first day, his oxygen was found to be low, and he was transferred to the ICU for intubation and monitoring. A physician also prescribed heparin injections to prevent blood clots.

The second day, the patient remained in restraints and sedated.

On the third day, the patient was taken off intubation and seemed to be improving physically, though was still exhibiting mental health symptoms, including paranoia. He refused two of the three daily dosages of heparin. He remained in restraints.

In the early afternoon of day four, the patient was discharged into the care of the VA police who escorted him in bilateral wrist restraints for involuntary transfer to a non-VA mental health treatment facility. However, that facility refused to accept him because he was in restraints. Consequently, at 8 p.m. the patient arrived back at the VAMC’s emergency department on a stretcher and in restraints, which were eventually removed.

At 8:40 p.m., a nurse arrived to give him his sedatives and found that, though he seemed to be breathing, he was not registering blood pressure. A physician found that while he had a pulse, he wasn’t breathing. The medical team began cardiopulmonary resuscitation but failed to revive the patient. He was pronounced dead at 9:23 p.m.

The medical examiner would eventually list the cause of death as “bilateral pulmonary thromboemboli with antemortem history of prolonged restraint.” The OIG report found that significant deficiencies throughout the patients care in the emergency department, inpatient medical unit, and the ICU likely contributed to that cause.

Haphazard Documentation

First, OIG investigators found that medical center staff were haphazard in documenting both medication administration and in examining the patient’s response to the drugs.

“The Emergency Department and Inpatient Medical Unit staff provided inadequate assessment and monitoring of the patient’s vital signs, administered unnecessary sedative medication, and Inpatient Medical Unit nurses inaccurately documented medication administration,” the report states. “The OIG concluded that the facility staff’s failure to monitor the patient’s response to medications and vital signs placed the patient at an increased risk of an adverse clinical outcome.”

The report also found that both the inpatient medical unit and the ICU staff improperly ordered medical surgical restraints when restraints were called for behavioral control. Restraints for behavioral control require more frequent assessment and observation. Investigators also found that the ICU staff kept the patient in restraints excessively without a physician’s order.

This lack of assessment and the use of restraints when none were ordered resulted in the patient being restrained for approximately 71 hours straight.

While the records show that nursing staff documented the patient refusing heparin doses, there was no record that a physician was informed or that anyone spoke to the patient about the importance of deep vein thrombosis prevention.

“The OIG concluded that the staff’s failure to effectively address the patient’s deep vein thrombosis prophylaxis needs contributed to the patient’s death,” the report states.

A failure by facility providers to properly assess the patient’s mental health on admission likely also contributed to his death, the report found.

If a full assessment of the patient’s mental illness had been conducted, his psychiatric conditions could have been prioritized. Instead, the patient was admitted for a nonemergent chronic medical condition, and his mental health symptoms were managed with sedation and restraints.

“The OIG would have expected a mental health provider to be involved on day 1 to provide recommendations regarding the patient’s mental health treatment and symptom management prior to the second code gray event,” the report states. “If a mental health provider was involved earlier, the patient’s nicotine dependence may have been handled more effectively and strategies other than sedation and restraint may have been identified to manage the patient’s agitation.”

Investigators found that mental health coverage was spread thin at the facility and that many instances where a psychiatric consult was needed, such a code gray, did not always include one.

The OIG made 18 recommendations to the VAMC director ranging from strengthening medication management to provider education about restraints. The VAMC has since evaluated its inpatient mental health consult process and begun filling in gaps in care. According to the hospital, the OIG’s investigation also resulted in three nurse leaders being disciplined.