Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection

Questionable Cause of Death 

VA Puget Sound Health Care System 

Seattle, Washington

Report No. 08-02620-22 November 12, 2008

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

Executive Summary 

The purpose of this inspection was to determine the validity of the following allegations 

regarding the death of a patient at the VA Puget Sound Health Care System (VAPSHCS) 

in Seattle, WA: 

• The patient’s death was caused by equipment failure and not aspiration pneumonia. 

• Staff did not communicate to the complainant that the patient “choked” and had to be 

suctioned prior to his death. 

• The physician did not accurately annotate the cause of death (COD) on the official 

death certificate. 

We substantiated that there was a nonfunctional suction machine, but we could not 

confirm whether the delay in clearing the patient’s airway was a contributing factor in his 

death. Progress notes clearly documented the patient’s declining condition prior to the 

equipment failure. We determined that community living center (CLC) nurse managers 

needed to clarify suction equipment procedures, assess staff competency with suction 

equipment, and conduct regular checks to ensure that suction equipment is functional. 

We also determined that an incident report should have been filed for the equipment 

failure event. 

We substantiated that clinical staff did not communicate to the complainant that the 

patient experienced aspiration and had to be suctioned shortly before his death. We 

determined that CLC staff should have discussed this event with the complainant and 

completed a clinical disclosure note in the medical record. 

We did not substantiate an inaccurate annotation of the COD (aspiration pneumonia and 

Alzheimer’s disease) on the death certificate. We determined that miscommunication 

could have been avoided had the physician explained aspiration pneumonia more 

completely and ensured that the complainant fully understood the explanation. 

We also determined that agency staff competencies should cover the specific care needs 

of the long-term care patient population. CLC nurse managers did not validate agency 

staff competencies for the long-term care patient population. 

We recommended that VAPSHCS managers take action to ensure functionality of suction 

equipment, reinforce compliance with requirements related to incident reporting and 

disclosure of unexpected events, ensure clinicians explain medical conditions in simple 

terms and elicit verbal understanding from the patient and/or family, and validate agency 

staff competencies related to CLC patients. The Veterans Integrated Service Network 

and VAPSHCS Directors agreed with the findings and recommendations and provided an 

acceptable action plan. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 20 

SUBJECT: Healthcare Inspection – Questionable Cause of Death, VA Puget Sound 

Health Care System, Seattle, Washington

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections reviewed 

allegations regarding the death of a patient in the community living center (CLC)1

 at the 

VA Puget Sound Health Care System’s (VAPSHCS) American Lake (AL) Division. The 

purpose of this inspection was to determine the validity of the following allegations: 

• The patient’s death was caused by equipment failure and not aspiration pneumonia. 

• Staff did not communicate to the complainant that the patient “choked” and had to be 

suctioned prior to his death. 

• The physician did not accurately annotate the cause of death (COD) on the official 

death certificate. 

Background 

The OIG received a complaint from the wife of a patient (the complainant) alleging that 

the cause of her husband’s death in June 2008 was due to equipment failure and not 

aspiration pneumonia.2

 At the time of his death, clinicians told the complainant that her 

husband had passed away peacefully, and she was satisfied with that explanation and the 

care provided. However, in July, the complainant received an anonymous phone call 

stating that her husband had actually died as a result of a nonfunctional suction machine 

when he aspirated (“choked”)3

 as he was being fed by an agency nurse. As a result, the 

complainant felt that she had been lied to because CLC staff did not inform her of the 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 

2

 Pneumonia is an inflammation of the lung caused by an infection. Aspiration pneumonia is a lung infection caused 

by inhaling stomach contents, food, or mouth secretions. It occurs most often in patients who have difficulty with 

their swallowing or gag reflex. The gag reflex keeps material from entering the lungs and causing infection. 3

 To aspirate is to draw in food or gastric contents into the lungs while inhaling. 

VA Office of Inspector General 1 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

aspiration and equipment failure incidents. In addition, the complainant felt that the 

physician did not properly annotate the COD on the death certificate. The death 

certificate listed aspiration pneumonia and Alzheimer’s disease as the COD. 

The VAPSHCS is a two-division tertiary facility located in Seattle and Tacoma, WA. It 

has 504 beds and 3,355 employees. In fiscal year 2008, the medical care budget was 

approximately $483 million. The VAPSHCS is part of Veterans Integrated Service 

Network (VISN) 20. 

Scope and Methodology 

We interviewed the complainant by phone. We conducted a site visit at the VAPSHCS’s 

AL Division in August 2008 and interviewed CLC nursing staff and managers; a 

physician; and a Supply, Processing, and Distribution (SPD) employee. We were unable 

to reach the involved agency nurse despite repeated attempts to contact her. We 

reviewed documentation, including the patient’s medical records and death certificate, 

staff training and competency records, and equipment maintenance reports. The scope of 

our review was limited to the allegations made by the complainant. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Inspection Results 

Case Review 

The patient was a male veteran in his late 70’s who was diagnosed with Alzheimer’s 

disease in 1999. In 2004, he was admitted to the VAPSHCS’s AL Division’s CLC 

Dementia Special Care Unit. His past medical history included aspiration pneumonia 

secondary to Alzheimer’s disease, dementia, and upper gastrointestinal bleed. The 

patient experienced a gradual decline in health during his hospitalization of more than 

3 years. At the time of admission, his wishes for “Do Not Resuscitate” were made 

known. His plan of care documented that he was non-ambulatory, totally dependent for 

his activities of daily living, and frequently unresponsive to verbal stimuli. 

In early June 2008, the patient had three episodes of vomiting dark secretions and was 

taken from the CLC to the emergency room for evaluation. Clinicians ordered diagnostic 

blood and radiology tests. The patient’s white blood cell count was slightly elevated at 

13,700 (normal range is 4,000–10,000), and his abdominal x-ray showed signs of left 

upper quadrant ileus (obstruction). Clinicians discussed his condition with the 

complainant, and the plan was to treat him conservatively on the CLC. 

The next day, the patient experienced three additional episodes of vomiting dark 

secretions, one of which tested positive for blood. Clinicians monitored the patient’s 

VA Office of Inspector General 2 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

condition, documented his steady deterioration, and communicated treatment and care 

changes to the complainant. A nurse documented that the patient was “...making 

moaning and groaning sounds. Patient continues to be non-verbal...LS [lung sounds] 

bilaterally coarse. Audible gurgling sounds noted....” 

The following morning, the physician noted that the patient continued to deteriorate. The 

physician’s assessment was “Likely aspiration pneumonia. UGI [upper gastrointestinal] 

bleed.” The physician spoke to the complainant and documented that care would 

concentrate on comfort measures only. At approximately 1:00 p.m., while attempting to 

take fluids orally, the patient choked and vomited black colored material. A nurse did 

suction the patient and cleared his airway, but within minutes, his respirations ceased. 

The patient was pronounced dead at 1:05 p.m. 

Issue 1: Equipment Failure 

We substantiated that equipment failure occurred due to a nonfunctional suction machine, 

but we could not confirm whether the delay in clearing the patient’s airway was a 

contributing factor in his death. Progress notes clearly documented the patient’s 

declining condition. According to the death certificate, the COD was Alzheimer’s 

disease and aspiration pneumonia. The providers we interviewed stated that the delay in 

suctioning the patient did not hasten or cause his death. Because the patient’s death was 

expected and imminent, no autopsy was performed. 

On the morning of the patient’s death, the registered nurse (RN) noted that the filter and 

connector tubing were missing from the suction machine at the patient’s bedside. The 

RN contacted SPD for replacement parts. SPD staff verified that they received a request 

to replace the missing parts but stated that urgency was not communicated at that time. 

Later that day, around 1 p.m., the patient aspirated while being given liquids by the 

agency licensed practical nurse (LPN).4

 The RN was summoned and after realizing that 

the replacement parts for the suction machine had not arrived from SPD, obtained the 

backup machine from the dining room (approximately 60 feet away from the patient’s 

room) and suctioned the patient. 

For patients on aspiration precautions, the standard of practice is that suction machines be 

readily available at the bedside and fully operational. It appeared that a combination of 

unclear procedures and lack of competence resulted in the presence of the inoperable 

machine at the patient’s bedside. The tubing and filter should not have been removed, 

the inoperable machine should have been replaced immediately, and the LPN should 

have ensured that the machine was working before feeding the patient. CLC nurse 

managers needed to clarify suction equipment procedures, assess staff competency with 

 

4

 This individual was contracted to perform nursing assistant duties at the AL Division for 13 weeks beginning 

April 2008. 

VA Office of Inspector General 3 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

suction equipment, and conduct regular checks to ensure functionality of suction 

equipment. 

Also, we did not find a written incident report for this equipment failure. Veterans 

Health Administration (VHA) policy requires the reporting of system vulnerabilities so 

that a facility can take appropriate actions to decrease the chances that this type of 

incident could recur. Nurse managers needed to reinforce compliance with incident 

reporting requirements. 

Issue 2: Communication 

We substantiated the allegation that staff did not discuss with the complainant that the 

patient aspirated and had to be suctioned prior to his death. Clinicians told us that their 

immediate concern at the time was to not burden the complainant with unnecessary 

information that could cause further grief. While it is unclear whether the patient’s death 

was hastened, the presence of a nonfunctional suction machine at the patient’s bedside 

resulted in a delay in clearing the patient’s airway. As a result, during our interview with 

the complainant, she felt that CLC staff lied to her and covered things up. Clinicians 

should have openly discussed the incident with the complainant and completed a clinical 

disclosure note in the medical record. 

Studies have shown that patients’ and families’ reactions to incidents are influenced both 

by the incident itself and how the incident is handled.5

 Discussing incidents openly with 

patients and family members is consistent with VHA’s core values of trust, respect, 

excellence, commitment, and compassion. Had CLC staff informed the complainant of 

the incident at the time of or immediately after the patient’s death, the anguish and anger 

the complainant experienced after hearing of this incident from an anonymous caller 

could have been alleviated. 

Consistent application of clinical discussion and disclosure of incidents, including honest 

discussion of what happened and explanation of what will be done to prevent future 

incidents, will enable the VAPSHCS to maintain a positive and trusting relationship with 

patients and families. Open discussions promote patient safety by encouraging clinicians 

to seek system improvements that minimize the likelihood of recurrence. VAPSHCS 

managers needed to reinforce compliance with disclosure requirements. 

Issue 3: Death Certificate 

We did not substantiate the allegation that the physician inaccurately annotated the COD

on the death certificate. Both aspiration pneumonia and Alzheimer’s disease are 

documented in the medical record. In June, the complainant had contacted the physician 

 

5

 Massachusetts Coalition for the Prevention of Medical Errors, “When Things Go Wrong: Responding to Adverse 

Events,” A Consensus Statement of the Harvard Hospitals, Burlington, MA, March 2006. 

VA Office of Inspector General 4 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

who signed the death certificate and questioned pneumonia as the COD. Even after 

discussion with the physician, the complainant still did not accept that the patient could 

have died of pneumonia. 

During our interview with the complainant, she stated that she found it difficult to 

understand how pneumonia was a cause of death because the patient had no fever, 

coughing, or other symptoms she associated with pneumonia. It seemed evident that she 

did not understand that aspiration pneumonia was a major underlying condition 

contributing to the patient’s death. It was only after our explanation that she seemed to 

understand and then accept the COD. This miscommunication might have been avoided 

if the physician had elicited verbal understanding from the complainant when he 

explained the diagnosis of aspiration pneumonia to her. 

Issue 4: Staff Competency 

In reviewing the competency records of the nursing staff who cared for the patient, we 

noted that the agency LPN was assigned to perform nursing assistant duties to long-term 

care patients in the CLC. Although the agency had provided an acute care competency 

checklist for this LPN, we did not find evidence of long-term care competencies. The 

Joint Commission requires organizations to assess staff competencies based on the 

population served.6

 VA further requires that staff must demonstrate competencies related 

to both the specific population and the specific services provided.7

 Orientation for 

agency staff working in the CLC should require a competency assessment for the 

long-term care patient population and their specific care needs that includes—but is not 

limited to—age-specific care, aspiration precautions or prevention, and end-of-life care 

goals. During our site visit, CLC managers agreed and began to address this deficiency 

by creating a staff development coordinator position, which will facilitate consistent 

validation of staff competencies. 

Conclusions 

We concluded that equipment failure occurred but could not determine whether the delay 

in clearing the patient’s airway was a contributing factor in his death. CLC staff did not 

communicate to the complainant that the patient aspirated and had to be suctioned shortly 

before his death or that the suction machine at his bedside was inoperable. Staff should 

have filed an incident report and documented clinical disclosure in the patient’s medical 

record. The death certificate accurately listed the COD as aspiration pneumonia and 

Alzheimer’s disease. The clinician did not ensure that the complainant fully understood 

the explanation of aspiration pneumonia as a COD. CLC nurse managers did not validate 

agency staff competencies for the long-term care patient population. 

 

6

 The Joint Commission, Comprehensive Accreditation Manual for Long Term Care, 2007, HR.3.10. 7

 VHA Directive 2006-014; Admission Criteria, Service Codes, and Discharge Criteria for VA Nursing Home Care 

Units (NHCU); March 24, 2006. 

VA Office of Inspector General 5 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington 

Recommendations 

Recommendation 1. We recommended that the VISN Director requires the VAPSHCS 

Director to ensure that CLC nurse managers clarify suction equipment procedures, assess 

staff competency with suction equipment, and conduct regular checks to ensure that 

suction equipment is functional. 

Recommendation 2. We recommended that the VISN Director requires the VAPSHCS 

Director to reinforce staff compliance with requirements related to incident reporting and 

disclosure of unexpected events. 

Recommendation 3. We recommended that the VISN Director requires the VAPSHCS 

Director to ensure that clinicians explain medical conditions in simple terms and elicit 

verbal understanding from the patient and/or family. 

Recommendation 4. We recommended that the VISN Director requires the VAPSHCS 

Director to direct responsible managers to validate agency staff competencies related to 

CLC patients. 

Comments 

The VISN and VAPSHCS Directors agreed with the findings and recommendations and 

provided an acceptable action plan. (See Appendixes A and B, pages 7–11, for the full 

text of the Directors’ comments.) We will follow up on the planned actions until they are 

completed. 

 (original signed by:) 

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 6 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: September 30, 2008 

From: Network Director, VISN 20 (10N20) 

Subject: DRAFT REPORT – Healthcare Inspection – Questionable 

Cause of Death, VA Puget Sound Health Care System, Seattle, 

Washington, Project Number: 2008-02620-HI-0174 

To: Director, Los Angeles Regional Office of Healthcare Inspections, 

(54LA) 

Thru: Director, Management Review Service (10B5) 

1. Attached you will find VA Puget Sound Health Care System’s response 

with their action and implementation plan to each of the recommendations. 

2. If you have any questions regarding this response, please contact 

Robin Cook, Director, Quality Improvement at (206) 764-2650. 

(original signed by Michael Fisher, Deputy Network Director, for:) 

Dennis M. Lewis, FACHE 

Attachments

VA Office of Inspector General 7 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

Appendix B 

Health Care System Director Comments 

Department of 

Veterans Affairs Memorandum

Date: September 29, 2008 

From: Director (663/S-00), VA Puget Sound Health Care System, Seattle, 

WA 

Subject: DRAFT REPORT – Healthcare Inspection – Questionable 

Cause of Death, VA Puget Sound Health Care System, Seattle, 

Washington, Project Number: 2008-02620-HI-0174

To: Director, Los Angeles Regional Office of Healthcare Inspections, 

(54LA) 

Thru: Director, Management Review Service (10B5) 

VA Puget Sound Health Care System (VAPSHCS) concurs with each of 

the findings and recommendations in the draft report. Please find the 

following action and implementation plans in response to each of the 

recommendations. 

If you have any questions regarding this response, please contact Robin 

Cook, Director, Quality Improvement, at (206) 764-2650. 

(original signed by:) 

Stan Johnson 

VA Office of Inspector General 8 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

Health Care System Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s Report: 

Recommendation 1. We recommended that the VISN Director requires 

the VAPSHCS Director to ensure that CLC nurse managers clarify suction 

equipment procedures, assess staff competency with suction equipment, 

and conduct regular checks to ensure that suction equipment is functional. 

a. Sterile Processing Department (SPD) has confirmed that 100% of 

suction machines are in full operating order upon leaving their department. 

A comprehensive test of each suction machine is conducted by SPD prior to 

delivery to point of service. 

b. All CLC nursing staff attended a mandatory in-service held in multiple 

sessions on August 26, 27, and 28, 2008, where Nursing and SPD reviewed 

the CLC procedures and manufacturer’s guide to proper setup and use of 

the suction machines. In addition, the presentation was reviewed to 

reinforce Patient Incident Reporting procedures related to equipment, as 

well as other incidents. Training was completed by all current on-duty staff 

on all shifts. For the few who could not attend the in-services, one-to-one 

training was provided by the Staff Development Nurse or Nurse Managers. 

(Only one staff member who is on extended sick leave has not completed 

the training.) The Staff Development Nurse and SPD staff will continue to 

provide this training for all returning or incoming new staff, including 

agency or contract staff. 

c. Prior to the hotline inspection August 6–7, 2008, procedures were in 

place for daily checks of suction equipment by the CLC charge nurse or 

designee. Daily check procedures and procedures for managing 

non-functioning equipment were discussed and reinforced during the 

September 17, 2008, nursing staff meeting. All suction machines have 

continued to receive routine daily checks since the hotline inspection and 

have been found to be in operating order 100% of the time. 

d. CLC Nursing leadership (Director of Nursing, Nurse Managers for CLC 

and Dementia Special Care Unit) held a joint meeting with SPD staff and 

supervisor on August 19, 2008, and agreed that SPD will respond 

VA Office of Inspector General 9 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

immediately with replacement parts or equipment when contacted about a 

non-functioning suction machine or other critical equipment. 

Recommendation 2. We recommended that the VISN Director requires 

the VAPSHCS Director to reinforce staff compliance with requirements 

related to incident reporting and disclosure of unexpected events. 

a. An Outlook message was sent by the Nurse Manager on 

August 11, 2008, and again September 26, 2008, to CLC staff to remind 

them that it is a requirement of the institution’s Patient Safety Program and 

organizational policy to complete Patient Incident Reports for all observed 

actual and potential safety issues so that they may be trended and 

opportunities to improve identified. 

b. The September 17, 2008, nursing staff meeting emphasized that Patient 

Incident Reports must be completed when actual or potential events 

impacting patient safety are observed. 

c. VAPSHCS currently conducts ongoing patient safety rounds where the 

Director of Patient Safety and Executive Leadership talk directly with front 

line staff about patient safety. The topic of incident reports and their 

importance to the overall Patient Safety Program will be routinely included 

in the rounds along with emphasis on expectations and procedures for 

incident reporting. These rounds follow a template for questions and 

answers. This topic was added to the template to assure consistent attention 

to this issue as of September 26, 2008. 

d. The Director of Patient Safety will prepare an announcement for the 

electronic weekly bulletin to all staff reinforcing the organizational incident 

reporting expectations and procedures by October 3, 2008. 

Recommendation 3. We recommended that the VISN Director requires 

the VAPSHCS Director to ensure that clinicians explain medical conditions 

in simple terms and elicit verbal understanding from the patient and/or 

family. 

a. CLC clinicians have been notified to use simple terms and elicit verbal 

understanding from the patient and/or family in critical situations such as 

this. In addition, a facility-wide reminder/training will be provided to 

clinicians regarding clear communication, understanding the literacy level 

of patients and families, avoidance of jargon, eliciting verbal feedback of 

understanding, etc. This will take place during the next scheduled meetings 

of the Medical Staff and the Clinical Executive Board.

VA Office of Inspector General 10 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

b. Quality Improvement Service in coordination with the Chief of Staff 

will develop and implement a CPRS clinical disclosure template by 

December 1, 2008, which will be communicated to the widest clinician 

audience, including the Clinical Executive Board and other service line 

medical staff meeting attendees. Use of this template will be tracked 

through Quality Improvement Service and presented to the Clinical 

Executive Board quarterly. 

c. A more effective system of debriefing after unexpected events is being 

designed in order to prevent miscommunication. This system will include 

eliciting responses to confirm comprehension and understanding. 

Implementation is planned for December 2008, involving the CLC’s 

psychologist, and with emphasis on “caring for the caregiver.” 

Recommendation 4. We recommended that the VISN Director requires 

the VAPSHCS Director to direct responsible managers to validate agency 

staff competencies related to CLC patients. 

a. A CLC nursing competency checklist specific for long-term care has 

been in use and was updated by the CLC Nurse Managers, approved by the 

Nurse Executive, and implemented immediately following the Inspector 

General site visit. 

b. The requirement for all staff to be reviewed for competency was 

reiterated with CLC Nurse Managers. The requirement to validate 

competency for all contract staff will be monitored for the next 90 days to 

ensure compliance. 

VA Office of Inspector General 11 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Julie Watrous, RN, Director 

Los Angeles Office of Healthcare Inspections 

(213) 253-2677 ext.4972 

Daisy Arugay, MT 

Mary Toy, RN 

VA Office of Inspector General 12 
Questionable Cause of Death, VA Puget Sound Health Care System, Seattle, Washington

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Northwest Network (10N20) 

Director, VA Puget Sound Health Care System (663/00) 

Non-VA Distribution

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senators: Patty Murray, Maria Cantwell 

U.S. Representatives: Norman D. Dicks, Jay Inslee, Rick Larsen, Jim McDermott, 

David Reichert, Adam Smith 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 13