Healthcare Inspection – Alleged Quality of Care Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California

At the request of the then Congresswoman Lois Capps, OIG conducted a healthcare inspection to assess quality of care concerns in the management of a patient at the VA Greater Los Angeles Healthcare System (system), Los Angeles, CA and from a home health agency contracted by the system. We did not substantiate that the patient received poor care while an inpatient at the system. We determined that the patient received appropriate care in response to his medical needs. Throughout his almost 3-week stay, the patient had 12 consultations from various clinical services and 2 gastrointestinal procedures. We could not substantiate that the patient had maggots in his underwear the day after he left the system because it could not be proven if or when the presence of maggots occurred. We found no documentation regarding maggots prior to the patient leaving the system or by the Emergency Department staff who examined the patient at a local community hospital a few hours after the patient left the system and again the following day. We could not substantiate that the home health agency provided poor care to the patient once he was in his own home because the office that provided services had since closed, the staff who cared for him were no longer employed by the agency, and no agency treatment records could be located. We identified inconsistent compliance with the nursing documentation requirements in the electronic health record of the patient’s pressure ulcers regarding wound location, drainage information, improvement, and wound characteristics, as required. We also found inconsistent documentation of collaboration and participation by providers/physicians related to the patient’s pressure ulcer. We recommended that nursing staff comply with pressure ulcer documentation requirements and physician providers routinely document participation in the interdisciplinary plan for patients with pressure ulcers.