Healthcare Inspection – Staffing and Quality of Care Issues in the Community Living Center, Charlie Norwood VA Medical Center, Augusta, Georgia

OIG conducted an inspection in response to allegations concerning staffing and quality of care issues resulting in patient harm and death in the community living center (CLC) at the Charlie Norwood VA Medical Center (facility), Augusta, GA. We substantiated that the facility was without one of three registered nurse (RN) Certified Wound Care Specialists for over a year. We did not substantiate that several patients’ wounds were neglected as a result of the vacancy. While we found that one patient had several pressure wounds, we determined that the care for this patient’s wounds was acceptable. We substantiated the allegation that a patient had a wound vacuum assisted closure (VAC) device that nurses and physicians failed to maintain. We found that the sponge from the wound VAC adhered to the wound and required removal. We concluded that the lack of training may have contributed to a delay in care. We did not substantiate that the primary care provider failed to send a patient to the inpatient medical unit earlier during the day, which resulted in a code being announced later that evening. We also did not find that the patient provided a written statement regarding the incident and that the facility failed to address it. We substantiated that a patient developed several wounds that needed debridement. However, we did not determine that it was due to the lack of an RN wound care specialist onsite. We recommended that the Facility Director require that all nursing staff in the CLC receive the required training on the wound VAC device.