DETROIT (AP) — A man who had bypass surgery died at a VA hospital in Michigan last year after a nurse mistakenly believed he didn't want to be resuscitated in an emergency, investigators said Tuesday.

As a result, the nurse no longer provides direct care, investigators said, noting that it was the third time in four years that he was "involved in significant monitoring deficiencies in high-risk patients."

No names were released in the report by the inspector general at the Department of Veterans Affairs.

The man was admitted to the VA hospital in Ann Arbor in 2016 for surgery to relieve leg pain from a blocked artery. He had other health problems, including cancer, diabetes and a family history of coronary disease, the report said.

While recovering from surgery, the patient complained about chest pain and nausea. A nurse left the room to get an electrocardiogram machine, but the man was unresponsive with abnormal breathing when the nurse returned, the report said.

The nurse told other medical staff that the man's status was "do not attempt resuscitation." That was wrong and he died.

The nurse told investigators that he was watching two other patients that day and became confused about resuscitation orders.

"It should be noted that, based on the totality of the facts and circumstances, it is not clear whether resuscitation efforts would have been successful if employed at the time," the report said.

Nonetheless, the incident was "particularly disturbing" because the hospital a year earlier had identified problems with confirming resuscitation status when a patient's condition was deteriorating, investigators said.

In response to the report, the Ann Arbor hospital said a nurse or a supervisor will independently verify resuscitation orders in an emergency.

VA spokesman Curt Cashour said employees could face sanctions.

VA Secretary David Shulkin "has made clear that VA will hold employees accountable when they fail to live up to the high standards taxpayers expect from us. And that's exactly what we're doing in this case," Cashour said.

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