Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Review of an Unexpected Death 

North Chicago VA Medical Center 

North Chicago, Illinois 

Report No. 09-03245-53 December 22, 2009

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

Executive Summary 

The purpose of the review was to determine the validity of allegations regarding the care 

provided to a patient who died within 24 hours of admission to the North Chicago VA 

Medical Center (the VAMC). The complainant suggested that a medical trainee may 

have been inadequately supervised. 

We found deficiencies in the quality of care provided for this patient, but we did not 

demonstrate a connection with the patient’s death. A physician conducted an evaluation 

approximately 5 hours before the patient’s cardiopulmonary arrest, but the patient’s 

subsequent restlessness and hypoxemia should have prompted an assessment of 

underlying causes prior to administration of an intravenous (IV) sedative. The sedative 

and an IV narcotic were administered at reasonable doses, but this combination might 

best have been avoided during a pursuit of an explanation for his restlessness and 

hypoxemia. Although the VAMC has a procedure in place for the expeditious 

assessment of patients whose condition is worsening, physician and nursing personnel did 

not take advantage of this resource. 

We recommended that management officials evaluate this case with Regional Counsel 

for possible disclosure to the patient’s family and ensure that staff comply with the 

VAMC’s policy for rapid intervention in patients with deteriorating clinical conditions. 

Management submitted appropriate implementation plans. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Great Lakes Health Care System (10N12) 

SUBJECT: Healthcare Inspection – Review of an Unexpected Death, North 

Chicago VA Medical Center, North Chicago, Illinois 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections (OHI) 

received allegations regarding the death of a veteran soon after admission to the North 

Chicago VA Medical Center (the VAMC). The purpose of this review was to determine 

whether the allegations had merit. 

Background 

The VAMC, part of the VA Great Lakes Health Care System (also known as Veterans 

Integrated Service Network (VISN) 12), provides care for veterans in northeastern 

Illinois and southeastern Wisconsin. The medical center also serves Department of 

Defense beneficiaries affiliated with the Naval Station Great Lakes. The VAMC is 

affiliated with the Rosalind Franklin University of Medicine and Science, Loyola 

University Chicago, and the University of Illinois. 

A complainant reported concerns about the care provided to a veteran who died within 

24 hours of admission to the VAMC. The complainant made no specific allegations 

about quality of care but suggested that a medical trainee may have been inadequately 

supervised. 

Scope and Methodology 

We interviewed the complainant by telephone and reviewed patient medical records. We 

also reviewed VAMC policies and quality management documents pertinent to the case. 

We performed the inspection in accordance with Quality Standards for Inspections 

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

VA Office of Inspector General 1 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

VA Office of Inspector General 2 

Inspection Results 

Case Summary 

A middle-aged man with a history of osteoarthritis of the hip, obstructive sleep apnea, 

and morbid obesity presented to the VAMC Emergency Department (ED) at 4:00 a.m. on 

a Sunday morning complaining of continuing left hip and leg pain. He stated that 3 days 

earlier he had received a steroid injection at a private facility, but that the pain had 

persisted. In the 2 months prior to this presentation he had been treated in the ED for the 

same problem on 12 occasions. 

In the ED he was described as having no pain approximately 30 minutes after receiving 

an intramuscular injection of ketorolac,1

 although he had been admitted to the hospital 

for pain control. It was noted that he lived alone. 

 

Following admission to the hospital, nursing documentation indicates that the patient was 

eating well and walking in the hall. Recurrent pain was well-managed with intravenous 

(IV) hydromorphone.2

 Approximately 14 hours after admission, an attending physician 

documented that he had discussed the patient with the resident physician (resident) and 

concurred with the plan of care. 

Approximately 22 hours after admission (5:05 a.m.), in a progress note describing events 

of the previous few hours, a registered nurse documented that the patient was: 

Restless, keeps getting up in bed and walking drowsy. Oxygen applied but 

[patient] takes it off. Dozing on and off while sitting at the edge of the bed 

and while walking. 

The nurse noted that the on-call resident physician “came to assess the patient,” but the 

resident did not document the encounter. Because the patient was considered to be at 

high risk for falling, at 1:00 a.m. the resident physician ordered 1:1 observation. 

A registered nurse recorded that the following medications were administered: 

zolpidem3

 5 mg (2:29 a.m.), hydromorphone 4 mg IV (2:45 a.m.), and lorazepam4 2 mg 

IV (4:37 a.m.). The patient’s oxygen saturation was noted to fall below 90 percent, and 

oxygen flow was increased from 2 to 4 liters/minute (administered by nasal cannula5

). 

The patient was noted to be asleep at 5:00 a.m. 

1

 A nonsteroidal anti-inflammatory drug. 2

 A narcotic analgesic. 

3

 An oral medication for sleep. 

4

 A sedating medication. 

5

 Plastic tubing with two prongs placed in the nostrils for delivery of supplemental oxygen. 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

At 6:20 a.m. the bedside sitter (for 1:1 observation) noticed that the patient was not 

breathing. Cardiopulmonary resuscitation was instituted immediately, and a Code Blue 

was called. Resuscitative efforts were unsuccessful, and the patient was pronounced dead 

at 7:30 a.m. An autopsy was performed, and the cause of death was described as 

“Probable spontaneous cardiac dysrhythmia, natural cause.” 

Findings 

The VAMC has a Medical Emergency Response System for patients with signs of 

deterioration, but the System was not activated. 

VAMC staff completed several reviews to assess the quality of care provided for this 

patient. 

Conclusions 

We found the quality of care reviews conducted by the VAMC to be thorough. 

We found deficiencies in the quality of care provided for this patient, but we did not 

demonstrate a connection with the patient’s death. A resident physician conducted an 

evaluation approximately 5 hours before the patient’s cardiopulmonary arrest, but the 

patient’s subsequent restlessness and hypoxemia should have prompted an assessment of 

underlying causes prior to administration of an intravenous (IV) sedative. The sedative 

and an IV narcotic were administered at reasonable doses, but this combination might 

best have been avoided during a pursuit of an explanation for this patient’s restlessness 

and hypoxemia. Although the VAMC has in place a procedure for the expeditious 

assessment of patients whose condition is worsening, physician and nursing personnel did 

not take advantage of this resource. 

Recommendations 

Recommendation 1. We recommended that the VISN Director ensure that the Medical 

Center Director evaluates this case with Regional Counsel for possible disclosure to the 

patient’s family. 

Recommendation 2. We recommended that the VISN Director ensure that the Medical 

Center Director requires that staff comply with the VAMC’s policy for rapid intervention 

in patients with deteriorating clinical conditions. 

VA Office of Inspector General 3 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

VA Office of Inspector General 4 

Comments 

The VISN Director and Medical Center Directors agreed with the findings and 

conclusions. (See Appendixes A and B for the Directors’ comments.) Management 

submitted appropriate implementation plans; we will follow up until all actions are 

complete. 

 (original signed by:) 

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

Assistant Inspector General for 

Healthcare Inspections 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 5 

Department of 

Veterans Affairs Memorandum

Date: November 9, 2009 

From: Director, VA Great Lakes Health Care System (10N12) 

Subject: Healthcare Inspection – Review of an Unexpected Death, North 

Chicago VA Medical Center, North Chicago, Illinois

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/KC) 

Director, Management Review Service (10B5) 

Attached please find the Review of an Unexpected Death draft 

response from North Chicago VA Medical Center. 

I have reviewed the draft report for North Chicago VA Medical 

Center and concur with the findings and recommendations. 

I appreciate the Office of Inspector General’s efforts to ensure high 

quality care to veterans and the active duty patients and families at 

the North Chicago VAMC. 

for and in the absence of

Jeffrey A. Murawsky, M.D. 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum

Date: November 9, 2009 

From: Director, North Chicago VA Medical Center (556/00) 

Subject: Healthcare Inspection – Review of an Unexpected Death, North 

Chicago VA Medical Center, North Chicago, Illinois

To: Director, VA Great Lakes Health Care System (10N12) 

I want to express my appreciation to the Office of Inspector General 

(OIG) for their professional and comprehensive review of an 

unexpected death here at the North Chicago VA Medical Center. 

I have reviewed the draft report for the North Chicago VA Medical 

Center and concur with the findings and recommendations. 

I appreciate the opportunity for this review as a continuing process 

to improve the care to our veterans and DoD patients. 

Patrick L. Sullivan, FACHE 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

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: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure that 

the Medical Center Director evaluates this case with Regional Counsel for 

possible disclosure to the patient’s family. 

Concur Target Date of Completion: December 4, 2009

In accordance with the Patient Safety handbook 1051.01 dated May 23, 

2008 and the VA Directive on Disclosure to Patients 2008-002 dated 

January 18, 2008 this facility will review the case for possible disclosure to 

the patient’s family. The attorney for North Chicago has this report and is 

reviewing the medical record, and other documents. A meeting will be 

arranged between Regional Counsel and medical staff leadership, Medical 

Center Director and other involved staff to discuss and determine the need 

for further disclosure. 

Recommendation 2. We recommended that the VISN Director ensure that 

the Medical Center Director requires that staff comply with the VAMC’s 

policy for rapid intervention in patients with deteriorating clinical 

conditions. 

Concur Target Date of Completion: January 15, 2010

Medical Emergency Response System (MERS) education was provided to 

residents in August and September, 2009. Processes were put in place to 

ensure that residents involve the attending physician in cases with patients 

with deteriorating clinical conditions. These included consulting with the 

attending prior to ordering I.V. narcotics; rounds that identified the on-call 

attending and a number to reach him/her; and, identifying all attending 

physicians on admission. Further education included discussion of the case 

with lessons learned at the M&M conference (8/21/09) and pain education 

(8/21/09). For nursing, a focused professional peer evaluation was 

conducted with 1:1 education on MERS and proper documentation for the 

VA Office of Inspector General 7 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

VA Office of Inspector General 8 

nurse (8/09). Additional education done for the entire nursing staff 

included review of the crash carts, MERS training and proper 

documentation (11/09). 

To reinforce the process: the rapid response initiation criteria will be 

distributed to all inpatient clinical staff including residents and nursing 

areas. A refresher in-service will be provided to all inpatient units. A 

hospital-wide Grand Rounds on this topic will be scheduled. 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Jerome E. Herbers, Jr., MD 

(202) 461-4658 

Acknowledgments Paula Chapman, CTRS 

Verena Briley-Hudson, MN, RN 

Judy Brown, Program Assistant 

VA Office of Inspector General 9 
Review of an Unexpected Death, North Chicago VA Medical Center, North Chicago, Illinois

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care System (10N12) 

Director, North Chicago VA Medical Center (556/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

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. Senate: Roland W. Burris, Richard Durbin, Russell D. Feingold, Herb Kohl 

U.S. House of Representatives: Melissa L. Bean, Mark Kirk, Donald Manzullo, 

Paul Ryan, Jan Schakowsky 

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

VA Office of Inspector General 10