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

Report Summary

Title: Healthcare Inspection - Quality of Care and Staffing Concerns, Salem VA Medical Center, Salem, Virginia
Report Number: 13-03604-198 Download
Issue Date: 6/23/2014
City/State: Salem, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted an inspection in response to quality of care and staffing concerns at the Salem VA Medical Center (facility), Salem, VA.

We substantiated that post-operative complications for orthopedic and podiatry surgery cases increased in fiscal year 2013. The facility has implemented corrective actions and is monitoring for effectiveness. We did not substantiate that bowel perforations occurred during surgery requiring ostomies; that a number of outpatients having lung biopsies required chest tube placements and admissions; that patients were being told that they had a spot on their lung and months later were told they had Stage IV lung cancer; or that a dying patient was inappropriately transferred from the emergency department to a medical/surgical unit. We also did not substantiate that the administrative officer of the day was admitting patients to units that could not properly care for them resulting in those patients being transferred within minutes of arrival. However, we did identify inefficiencies in the admission process and inter-unit transfer patterns.

We substantiated the subject unit had been staffed for 20 patients. In 2013, the unit’s bed capacity increased from 20 to 24 patients. Staffing initially remained the same while the facility monitored the average daily census to determine the unit’s resource needs. Additional nursing staff have been hired. We did not substantiate that the unit routinely received up to 15 admissions during an 8-hour shift.

We recommended that the Facility Director continue to monitor and address increases in post-operative infection rates and take appropriate corrective actions when indicated and evaluate the admission process from the emergency department, monitor inter-unit transfer patterns, and take corrective actions as needed.