Report Summary

Title: Healthcare Inspection – Patient Care Concerns at the Community Living Center, Hampton VA Medical Center, Hampton, Virginia
Report Number: 15-02009-227 Download
Issue Date: 5/11/2017
City/State: Hampton, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted a review at Senator Mark Warner’s 2015 request to assess complaints about the delivery of care at the community living center (CLC), Hampton VA Medical Center (facility), Hampton, VA. We substantiated that CLC staff did not consistently have competency validation completed for the care of residents (a term commonly used for patients in a CLC) with suprapubic catheters. We substantiated that CLC staff failed to carry out some physician orders for catheter irrigation. We substantiated that CLC staff did not consistently document checks for well-being and skin assessments. We did not substantiate that CLC staff failed to weigh residents, take vital signs, offer morning care, or address residents’ dining assistance needs. We did not substantiate that CLC staff made residents wait for care. We could not substantiate that weekend staff were not keeping the same routines for the residents or that residents were not informed of special events. We substantiated that in the past, residents had to go to the facility barbershop to be shaved. We found that resident call lights could be turned off at the nurses’ desk. Biomedical staff reconfigured the system so that a call light could only be shut off at a resident’s bedside. We could not substantiate that CLC staff left medications at a resident’s bedside and later tried to give the resident another dose that was still sitting at his bedside. We did not substantiate that CLC staff were not routinely cleaning or sanitizing durable medical equipment. We substantiated that procedures were not followed and an appropriate mattress was not obtained in a timely manner.

We recommended the Facility Director ensure CLC staff have competency assessments and validations completed for care of residents with suprapubic catheters, CLC staff carry out physician orders, CLC staff conduct and document resident checks for well-being, skin assessments, and activities of daily living assistance, and procedures are followed for obtaining special care beds and mattresses.