Report Summary

Title: Healthcare Inspection – Quality of Care Provided by a Nurse, John Cochran Division, St. Louis VA Medical Center, St. Louis, Missouri
Report Number: 12-00835-271
Issue Date: 9/12/2012
City/State: St. Louis, MO
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: OIG evaluated allegations regarding the quality of care provided by a nurse at the John Cochran Division, St. Louis VA Medical Center, St. Louis, MO. A complainant alleged that a registered nurse (RN) was involved in serious medication errors, and that management did not respond when complaints were brought to their attention.
The facility took appropriate actions in response to the allegations by removing the subject RN from patient care and initiating an Administrative Investigation Board (AIB) to review the alleged medication errors. The AIB substantiated the allegation of substandard care and we concurred with their findings and recommendations. We did not substantiate the allegation that management did not respond to prior complaints. We also reviewed the facility’s RN competencies, medication administration system, and quality and safety programs, and we made no recommendations.