Healthcare Inspection – Alleged Lapses in Communication and Poor Quality of Care, Charlie Norwood VA Medical Center, Augusta, Georgia

OIG conducted an inspection at the Charlie Norwood VA Medical Center in Augusta, GA, in response to allegations received through our Hotline Division and from Congressman Doug Collins’ office concerning poor patient care, lapses in communication between facility staff and the patient’s family, inadequate physician/nurse staffing, loss of the patient’s personal property, and failure to provide medical information to another facility. We substantiated that the patient developed pressure ulcers on his sacrum and coccyx after admission to the hospital and that documentation of care rendered to prevent ulcers was inconsistent. Since the facility is in the process of improving the prevention of pressure ulcer program and progress will be monitored through the Combined Assessment Program review follow-up, we made no recommendations concerning this allegation. We substantiated that facility staff and physicians failed to effectively communicate with the patient’s family regarding the patient’s condition and treatment needs. We substantiated that facility staff did not securely safeguard the patient’s personal belongings during the patient’s hospitalization. We did not substantiate the allegation that staff members expressed concern regarding inadequate nurse staffing levels. We found that nurse staffing levels in the intensive care unit met or exceeded target levels. We addressed the physician staffing levels in the context of resident physician communications with the family. We did not substantiate the allegation that the facility did not provide the private rehabilitation center with current patient health records. We recommended that the Facility Director (1) ensure that patient information is shared with patients, families, and significant others in an appropriate manner that protects patient privacy, and (2) ensure that processes be strengthened for inventory, documentation, storage, and retrieval of patient belongings, and that compliance is monitored.