Healthcare Inspection—Quality of Care and Patient Safety Concerns in the Community Living Center, James A. Haley VA Hospital, Tampa, Florida

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding patient safety and poor quality of care in the Haley’s Cove Community Living Center (CLC) at the James A. Haley Veterans Hospital (facility) in Tampa, FL. The OIG substantiated that with Resident A’s 2016 fall, CLC staff had not implemented fall precautions and the Emergency Department physician did not adequately evaluate his injuries. The OIG found Resident A’s injuries to be consistent with those experienced in a fall. The OIG did not substantiate that staff failed to properly notify the family after Resident A’s fall or that staff improperly kept him on a gurney. The OIG substantiated CLC staff used a smaller-sized urinary catheter on Resident A, but found no evidence that this negatively impacted him. The OIG determined that medication changes/adjustments were reasonable and that family consent was not required. Further, the nurse practitioner’s decision not to order a urinalysis was appropriate. The OIG found CLC staff did not implement Resident B’s fall precautions. Resident B fell in early 2017 and died 9 days later. From October 1, 2016 through March 31, 2017, the facility’s CLC exceeded VHA-wide rates for falls with major injuries. The OIG inspected 46 CLC residents’ rooms and found that CLC staff did not consistently implement fall precautions. The facility did not adequately review and follow up with Resident C’s 2015 allegations of abuse, but did review and follow up with Resident D’s and Resident E’s allegations of neglect and “rough” handling. The OIG did not substantiate family members’ concerns about possible retaliation from staff if they complained about care. On 2 selected days in February 2017, the OIG found CLC units met minimum staffing levels but not the registered nurse staffing mix recommendation. During OIG's unannounced visit, we found CLC units to be clean, odor free, and well-maintained. The OIG made six recommendations.