Healthcare Inspection – Restraint Use, Failure To Provide Care, and Communication Concerns, Bay Pines VA Healthcare System, Bay Pines, Florida

OIG conducted an inspection at the request of Congressman Daniel Webster to assess the merit of allegations that staff inappropriately restrained a patient both physically and chemically; failed to provide anticoagulation medications (Coumadin), fluids, food, and nursing/medical care; and failed to effectively communicate with the patient’s family at the Bay Pines Healthcare System (facility), Bay Pines, FL. We found that the patient was not inappropriately restrained during a computed tomography (CT) scan. CT technicians placed straps during the procedure for patient safety and to avoid sudden patient movement. We substantiated that during his Emergency Department (ED) and inpatient stay, the patient was physically restrained on three occasions due to his combativeness and attempts to interfere with medically necessary treatments. Nursing documentation of the use of restraints was consistent with facility policy; however, we did not find a physician’s order for the episode of restraint use when in the ED. We did not substantiate that the patient failed to receive care. The patient was admitted to a constant observation room on a medical unit. Staff was continuously present to immediately assist the patient if needed. We did not substantiate that the patient was not provided Coumadin because the facility did not have the medication in stock. The patient’s medication administration records showed appropriate adjustments of the times and doses of Coumadin. We substantiated that two patient advocates failed to act professionally when communicating with the patient’s family. We did not substantiate that facility staff refused to release the patient’s electronic health record to the family or that the electronic health record was altered. We substantiated that facility staff failed to effectively communicate with the patient’s family on multiple occasions.