Healthcare Inspection – Alleged Nursing Deficiencies Led to Patient's Death, Hampton VA Medical Center, Hampton, Virginia

OIG conducted an inspection to assess the validity of allegations that improper nursing care resulted in a patient’s death at the Hampton VA Medical Center, Hampton, VA. The complainant alleged that nursing staff did not conduct required rounds and failed to properly respond when staff received reports that the patient’s condition was deteriorating. The complainant also alleged that the patient’s health record was incomplete. We substantiated that the nursing staff did not perform patient rounds in accordance with the Medical Center policy, which requires a patient to be checked every 30 minutes. In addition, we found no documentation of actions taken when non-nursing staff notified Spinal Cord Injury staff of a change in the patient’s condition. We could not determine whether a failure to immediately assess the patient for possible problems led to this patient’s death. We recommended that the Hampton VA Medical Center Director initiate a review to evaluate patient rounds and electronic health record documentation policies, train and educate appropriate staff to ensure consistent adherence to patient assessment and documentation procedures, and consult with Regional Counsel regarding institutional disclosure.