Alleged Quality of Care Issues in the Community Living Centers, Northport VA Medical Center, New York

Report Information

Issue Date
Report Number
17-03347-290
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding quality of care issues in two Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated Patient A died at the facility after choking on food, but found insufficient evidence to attribute the cause of the choking to the lack of nurse staffing. The OIG substantiated the facility operator called the wrong code, leading to multiple responders, role confusion, and a delay in transporting Patient A to the Emergency Department. The OIG did not substantiate managers misrepresented the cause of death as cardiac arrest. OIG inspectors found inconsistent emergency medical response policies, post-code debriefings, and medical oversight and determined Patient A’s case warranted additional facility review. The evidence was insufficient for the OIG to substantiate or not substantiate whether patients were regularly left unsupervised while eating. The OIG did not substantiate one CLC lacked security due to malfunctioning door locks. The OIG substantiated a lack of consistent documentation of rounds but was unable to ascertain if this condition reflected an absence of completed rounds and decreased unit security. The OIG was unable to substantiate or not substantiate a lack of staff vigilance. The OIG substantiated Patient B’s wrists were bound together by a palm protector strap but did not find evidence to suggest an intentional act done by staff due to a lack of available nursing staff. The OIG did not substantiate that CLC nursing managers were often unavailable and failed to provide adequate response to unit issues. The OIG made eight recommendations to the Facility Director and one recommendation to the Veterans Integrated Service Network Director related to emergency medical response processes and policies, CLC meal staffing and delivery processes, safety rounds, and reviews of Patient A’s care.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director makes certain that staff conduct post-Code Blue debriefings as required and that compliance is monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director ensures the collection, review, and analysis of data following each Emergency Response Team event response and that those involving resuscitative care are reviewed by the Facility Cardiopulmonary Resuscitation Committee, and that compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director confirms that a review of the Community Living Centers’ meal staffing process is performed to evaluate the need for designation of a staff person responsible for assigning (both nurse and interdisciplinary team) and monitoring staffing levels in the dining hall throughout meal times and takes appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director completes a review of the meal delivery process in the CLCs to confirm and document menu selection and diet type at the time that meal trays are served to the patient and makes policy updates, if warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director verifies that Community Living Centers’ safety rounds are conducted and documented, as required, and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director confers with Office of General Counsel to determine if an institutional disclosure of Patient A’s care is warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director obtains peer reviews of the care provided by practitioners (including supervisors in the case of the resident physicians) during the emergency management of Patient A while in the Community Living Center and Emergency Department.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director reviews and updates, as warranted, Facility policies and practices related to emergency medical response (such as obtaining emergent intravenous access) and adequate medical oversight, and all staff (including resident physicians) complete training and compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 2 Director oversees and provides assistance to the Northport VA Medical Center Director in the review and update of Facility policies and practices on emergency medical response and adequate medical oversight.