Healthcare Inspection – Quality of Care and Other Concerns, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois

OIG conducted a healthcare inspection to assess allegations made by confidential complainants regarding quality of care and other concerns at the Captain James A. Lovell Federal Health Care Center (FHCC), North Chicago, IL. We substantiated the Home Based Primary Care program’s Joint Commission accreditation status was “threatened” after a March 2015 FHCC accreditation survey; however, in August 2015, the Joint Commission determined the program complied with accreditation standards. We substantiated a Community Living Center patient who fell had an inaccurately low Morse Fall Scale assignment and incomplete Morse Fall Scale Notes. We substantiated that Community Living Center patient falls increased during fiscal year (FY) 2014; however, facility leadership recognized the issue and completed an action plan, which led to a decrease in patient falls in FY 2015. We substantiated the Emergency Department (ED) was left unattended by a qualified physician when ED physicians left the ED to perform emergency airway management in other FHCC care areas. We substantiated the ED did not have clerical staff support on weekends and most weekdays during the dayshift; however, this did not conflict with Veterans Health Administration policy and did not negatively affect delivery of patient care. We did not substantiate the ED length of stay for admitted patients was long or that ED transfer rates were high. We substantiated nurses did not consistently follow proper hand-hygiene practices. We substantiated primary care providers referred Navy recruits to the ED for non-emergent care needs; however, we determined the practice was permitted to ensure recruits were ready for deployment. We did not substantiate FHCC staff mishandled the suicides of two individuals. We did not substantiate the medical/surgical unit length of stay was long. We did not substantiate the Associate Director of Inpatient Services lacked the required education and experience to qualify for the position. We made three recommendations.