Description of Event or Problem · 1
PATIENT HAD JARVIK 2000 VAD PLACED IN 2013. HE WAS ADMITTED ON (B)(6) 2017 WITH FATIGUE, COUGH AND 2 MECHANICAL FALLS, FATIGUE AND QUESTIONABLE PUMP STOPPAGES. ON THE DAY OF ADMISSION THE NURSE HEARD THE LVAD ALARM AND FOUND THE PATIENT UNRESPONSIVE. THE CONTROLLER AND PEDESTAL WIRES WERE CHANGED AND THE PATIENT RESUSCITATED. DURING THE SECOND INCIDENT, THE NURSE RESPONDED TO THE LVAD ALARM AND FOUND THE PATIENT DISCONNECTED FROM THE CONTROLLER. HE IMMEDIATELY WAS RECONNECTED AND REGAINED CONSCIOUSNESS. IT APPEARED THE PATIENT DISCONNECTED THE DEVICE. HE WAS EVALUATED BY PSYCHIATRY, DEEMED TO HAVE MILD TO MODERATE DEMENTIA BUT NOT DEEMED TO BE SUICIDAL. DURING THE 3RD INCIDENT, THE NURSE WAS NOTIFIED BY TELEMETRY THAT THE PATIENT WAS IN VENTRICULAR FIBRILLATION/TACHYCARDIA VF/VT). SHE IMMEDIATELY WENT INTO THE ROOM AND FOUND THE PATIENT IN A CHAIR UNRESPONSIVE, APNEIC, AND PULSELESS. THE LVAD BATTERY WAS DISCONNECTED BUT REPORTEDLY NO ALARMING. HE WAS RECONNECTED, BUT DID NOT RESPOND AND WAS PRONOUNCED DECEASED. FOLLOW-UP TESTING ON THE EQUIPMENT BY HOSPITAL'S BIOMED DEPARTMENT AND THE MFR FOUND NO EVIDENCE OF EQUIPMENT MALFUNCTION.