Report Summary

Title: Healthcare Inspection – Alleged Patient Safety, Medication Management, and Environment of Care Deficiencies in the Intensive Care Unit, Hampton VA Medical Center, Hampton, VA
Report Number: 12-02516-280
Issue Date: 9/17/2012
City/State: Hampton, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: At the request of Senator Jim Webb, OIG conducted a review to determine the validity of 13 allegations regarding nurse orientation and training, medication integrity and security, security over patient information, availability of medical supplies, patient monitoring and staff response to patient care needs, and environment of care issues at the Hampton VA Medical Center, Hampton, VA. The allegations largely focused on the Intensive Care Unit (ICU). We substantiated five of the allegations: (1) ICU medication refrigerator temperatures are frequently outside the appropriate range, (2) ICU medication carts do not always lock properly, (3) medical supplies are not adequately stocked in the ICU, (4) negative air pressure is not maintained in patient isolation rooms in the ICU and Step Down Unit, and (5) the ICU physician call schedule is not clear to nurses on the night shift. We did not substantiate six of the allegations and could neither confirm nor refute two of the allegations. In addition, we identified two issues related to telemetry monitoring. We made six recommendations that the Veterans Integrated Service Network and Acting Facility Directors agreed with and provided acceptable improvement plans for.