Report Summary

Title: Healthcare Inspection – Alleged Resident Abuse and Abuse Reporting Irregularities at the Pueblo Community Living Center, VA Eastern Colorado Healthcare System, Denver, Colorado
Report Number: 12-03858-46
Issue Date: 11/29/2012
City/State: Pueblo, CO
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection of the Pueblo Community Living Center (CLC), in Pueblo, CO, which is operated by the VA Eastern Colorado Health Care System, located in Denver, CO. The purpose of the inspection was to determine the validity of allegations regarding CLC resident abuse and reporting irregularities. We did not substantiate the allegation of resident abuse. We did not substantiate the allegation that staff attempted to cover up an allegation of abuse or that staff who report potential abuse are retaliated against; however, we found staff did not report allegations of abuse as required by VHA and local policies, and did not track or trend incidents such as bruises and skin tears of unknown origin in order to identify potential abuse patterns. We recommended that the system Director ensures all Associate Chiefs of Nursing and CLC staff are retrained on the requirements for reporting allegations of abuse and that procedures to report, log, track, trend, and analyze injuries of unknown origin at the CLC are developed.