Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York

OIG conducted a review to assess the merit of an allegation concerning an increased number of patient injuries due to “unnecessary roughness” by staff in the community living center (CLC) Canandaigua VA Medical Center in Canandaigua, New York. We did not substantiate the allegation. However, we found that since October 2011, the CLC experienced an upward trend in patient falls, with a spike in April and May 2012. Facility leaders were aware of the increase in patient falls and had taken steps to identify contributing factors and implement preventive strategies prior to our review. We found that the facility’s Falls Reduction Program could be strengthened and recommended that the facility Director implement procedures to ensure that CLC unit-level reviews of patient falls are patient-specific and address the specific circumstances surrounding the fall and that fall prevention interventions are documented in patient care plans. Management agreed with the findings and recommendations and provided an acceptable improvement plan.