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Healthcare Inspection – Quality and Patient Safety Concerns in the CLC, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina

Report Information

Issue Date
Report Number
13-01123-249
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

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 We substantiated that a high-risk resident could wander or elope from a CLC unit because of an outdated electronic monitoring system, and policy, practice, and training deficits.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.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Director ensure that the patient (case 1) endof-life care undergoes a quality review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Director ensure that CLC staff are appropriately trained and competent to care for all CLC residents, regardless of the residents' special care needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility Director conduct a risk assessment of the electronic monitoring system and implement improvements, as indicated.