Healthcare Inspection – Nurse Staffing and Patient Safety Reporting Concerns, VA Roseburg Healthcare System, Roseburg, Oregon

OIG conducted an inspection at the request of Congressman Peter A. DeFazio in response to allegations about inadequate nurse staffing in the Community Living Center (CLC) and patient safety reporting at the VA Roseburg Healthcare System (system), Roseburg, OR. We did not substantiate the allegation that the system’s CLC nurse staffing was inadequate and not in compliance with Veterans Health Administration policy. System leadership implemented VHA’s staffing methodology. We did not substantiate the allegation that failure to correctly staff the CLC units resulted in patient falls or employee injuries. The system, including the CLC, had a comprehensive approach to identifying high risk patients and managing fall prevention, although staffing levels were not consistently analyzed after a fall occurred. We did not substantiate the allegation that the CLC had no working alarms. Nurse call and elopement prevention system alarms functioned as required. We did not substantiate the allegation that patient safety concerns were not reported. Patient safety issues were communicated to leadership and incident reports completed. We repeatedly heard complaints of low staff morale; however, we determined leadership at both the system and Veterans Integrated Service Network level continued to take action regarding improving workplace culture. We made one recommendation.