Report Summary

Title: Healthcare Inspection – Quality of Care Concerns of a Surgical Patient, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
Report Number: 15-04516-229
Issue Date: 5/17/2017
City/State: Little Rock, AR
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: OIG conducted an inspection to assess allegations about a surgical patient’s care at the Central Arkansas Veterans Healthcare System (system), John L. McClellan Memorial Veterans Hospital, Little Rock, AR. We did not substantiate that physicians failed to examine the patient every day; electronic health record (EHR) documentation contained daily assessments. We did not substantiate that the patient was in bilateral wrist restraints continuously for over 30 days or that nursing staff did not follow physician orders regarding the patient’s activity level. EHR documentation showed restraints were used but removed periodically and nurses increased the patient’s activity level when ordered to do so. We found the system’s restraint policy did not require notification of system leaders of duration of medical restraint use. We did not substantiate that the use of restraints caused a full thickness tissue loss or that staff failed to address an issue with the patient’s foot and ankle. However, staff did not consistently follow the system’s policy regarding wound care documentation. We substantiated that a request for a transfer was denied but we did not substantiate that the denial was inappropriate. Services the patient needed were not available at the second hospital. We could not substantiate that nursing staff were making bets on how much medication they could give another patient to keep him quiet. The patient had a history of alcohol use but the EHR did not contain documentation that the surgical team offered preoperative detoxification; it is unknown, however, if the patient would have agreed to the offer. We made three recommendations: (1) ensure a peer review is conducted to determine if the risk of alcohol was adequately assessed and whether inpatient management was reasonable, (2) modify the restraint policy to include leadership notification of patients in medical restraints after specified timeframes, and (3) ensure wound care documentation is consistent with system policy.