Healthcare Inspection – Alleged Medication Cart Deficiencies and Unsafe Medication Administration Practices, Atlanta VA Medical Center, Decatur, Georgia

OIG conducted an inspection to evaluate allegations of medication cart deficiencies, unsafe medication administration practices, and insufficient leadership response to these problems at the Atlanta VA Medical Center, Decatur, GA. During an unannounced site visit, we found that four of the five carts used in the Community Living Center for medication pass had to remain plugged in due to insufficient battery power and some of the medication drawers on two of the carts did not lock. Of the 14 carts in service on the 7th and 10th medical floors, 5 had to remain plugged in due to short battery life and 6 had unsecurable medication drawers. The computers and scanners were functional on all 19-medication carts observed, but we noted that some computers were slow to operate or required multiple reboots. We found that due to inadequate and/or non-functional medication carts, nurses have had to administer medications late and that nurses did not consistently document the reason for late medication administration. We did not substantiate the allegations that due to inadequate and/or non-functional medication carts, nurses had to engage in workarounds; an approved alternate method was available for nursing staff to follow when administering medications. We substantiated that if nurses did not follow medication administration policies; they could be at risk professionally. While we confirmed ongoing problems with medication carts, we did not substantiate the allegation that leadership has not responded to complaints about the issue. We made three recommendations.