Vietnam Veteran Died Over Wrong DNR Order

Audit cites California VA hospital’s ‘confusion’ in patient’s death
Sun Herald
BY MICHAEL DOYLE
July 30, 2015

A Citrus Heights, Calif., resident, Mayo had served in the Army’s 101st Airborne Division and worked as a Riverside County deputy sheriff. He had a medical history that included hypertension and post-traumatic stress disorder when he entered the hospital for elective heart surgery.

WASHINGTON — An erroneous wristband placed on a 65-year-old Vietnam veteran caused a “delay in life-saving intervention” at the Mather VA facility in Sacramento, federal investigators say in a new report prompted by the patient’s death under questionable circumstances last October.

The wristband incorrectly identified patient Roland Mayo as having given a “Do Not Resuscitate” order, also known as a DNR.

The resulting “confusion” about Mayo’s status “delayed chest compressions, defibrillation pad placement, and medications” when he went into cardiac arrest, investigators with the Department of Veterans Affairs Office of Inspector General concluded. As a result, two precious minutes reportedly passed between the time Mayo’s pulse stopped and CPR began.

“The American Heart Association recommends initiating immediate chest compressions for adults suffering from sudden cardiopulmonary arrest,” investigators noted.

They further described a seemingly frantic scene on the day of Mayo’s death, during which so many medical personnel crowded into the patient’s room that they blocked the doorway and spilled out into the hallway.

“A nursing supervisor and physician requested several times for nonessential personnel to leave, but no one did so,” investigators noted. “Staff reported having difficulties hearing the physician’s orders throughout the code because there were so many people in the room.”
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