Workers disciplined after death of man at VA hospital

A patient who was improperly restrained for almost three days at a Veterans Affairs hospital in Georgia died with blood clots in his legs that likely were linked to the treatment, an inspector general report concluded.

The man, who was in his 60s but wasn’t otherwise identified, had been treated for mental health disorders including schizophrenia for years before his death at Charlie Norwood VA Medical Center last year, The Augusta Chronicle reported.

Three nurse leaders were disciplined and reforms were implemented because of what happened, said a statement by hospital director Robin E. Jackson, who was faulted in the report for having inadequate mental health consulting that could have led to better care.

The report also criticized a lack of training and review of restraint use, a lack of communication and a failure to adequately monitor the patient’s vital signs and to document medications given.

Jackson said the hospital “grieves for the loss of this veteran and extends our deepest condolences to their loved ones.”

The man showed up in spring 2019 at a VA office seeking his regular monthly medication despite having just received it, according to the report. The man became “very loud and aggressive,” according to staff reports, and police were called.

The man was placed in restraints in an inpatient unit and given sedation for a second time after threatening to kill a doctor, the report said. The man, who initially seemed healthy once the restraints were removed after more than 70 hours, was later found without a pulse and could not be revived.

The restraints likely contributed to leg blood clots that killed the veteran, the report said.