OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Quality of Care Issues, San Juan VA Medical Center, San Juan, Puerto Rico
Report Number: 13-01956-37 Download
Issue Date: 12/30/2013
City/State: San Juan, PR
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to review allegations from a confidential complainant about quality of care issues, inadequate discharge planning, and lapses in communication at the San Juan VA Medical Center (the facility), in San Juan, Puerto Rico. We substantiated the allegations that the medical condition leading to the patient’s acute delirium was not addressed, and that the patient was not medically stable when he left the facility. We substantiated the allegation that the patient lost a significant amount of weight while he was in the hospital, and determined that the patient’s nutritional treatment plan was inadequate. We substantiated the allegation that the patient fell once, that family members did not receive adequate information regarding the patient’s condition, and that no attempts were made by staff to arrange for appropriate follow-up care with providers at the Arizona VA facility.

We determined that accurate skin assessments were not performed, and that actions taken to prevent and/or treat pressure ulcers were inadequate. We recommended that thorough nutritional assessments are completed (including weights), processes be strengthened to ensure nursing staff perform accurate daily skin inspections, and that discharge planning processes are appropriate for the patient’s condition. We also recommended that the informed consent process complies with VHA requirements, and that the facility director consults with Regional Counsel regarding possible disclosure of failure to diagnose urinary tract infection and prevent and treat pressure ulcers.