Report Summary

Title: Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
Report Number: 13-01123-249
Issue Date: 7/22/2013
City/State: Salisbury, NC
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 (OIG) Office of Healthcare Inspections conducted an inspection in response to a complainant’s allegations of poor quality of care and patient safety concerns in the Community Living Center (CLC).
We generally did not substantiate that patients were improperly admitted to the CLC, and as a result, did not receive appropriate treatment and services. In one case, the resident did not receive care consistent with VHA’s defined concept of Hospice and Palliative Care. We substantiated that a high-risk resident could wander or elope from a CLC unit because of an outdated electronic monitoring system, and policy, practice, and training deficits. We did not substantiate that, to increase VERA funding, CLC leaders improperly admitted patients for rehabilitation, that CLC nurse practitioners were not supervised, or that the CLC Chief Nurse Executive does not adequately address and follow-up on staff concerns. Facility leaders had not, however, conducted a risk assessment of the electronic monitoring system in spite of ongoing safety concerns. OIG made three recommendations.