Alleged Poor Quality of Care in a Community Living Center at the Northport VA Medical Center, New York

Report Information

Issue Date
Report Number
17-03347-285
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
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 a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in a facility CLC and required surgery for a hip fracture sustained during the fall. The OIG did not substantiate that the patient’s fall was caused by inadequate fall precautions or that the patient’s death was caused by abuse or neglect. The OIG substantiated that the patient did not receive anticoagulation injections to prevent blood clots following surgery for hip fracture per facility protocol. The OIG did not substantiate that the failure to receive three of the four doses of anticoagulation medication during the hospital stay contributed to the patient’s death. The OIG was unable to substantiate or not substantiate that a staff member who performed one-to-one observation of the patient failed to provide proper observation during the shift when the patient died, because the OIG was unable to resolve discrepancies between facility documentation and staff interviews. The OIG did not substantiate that the CLC Nurse Manager received complaints about staff behaviors that negatively impacted patient care and failed to take corrective action. The OIG did not substantiate that facility leaders or managers tried to cover up the circumstances surrounding the patient’s death. However, the OIG determined that the missed anticoagulation medication doses were not addressed in the facility’s quality management review of the patient’s care. The OIG made three recommendations related to reviewing the accuracy of 24-Hour Observation Flow Sheets, conducting an updated quality management review of the patient’s case, and consulting with the Office of General Counsel about missed anticoagulation doses and institutional disclosure to the patient’s family.

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 ensures a review of Community Living Center 3’s 24-Hour Observation Flow Sheets is completed to determine the accuracy of documentation entered by all shifts for the past three months, beginning with the date of receipt of this report, and initiates an action plan to correct identified deficiencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director makes certain that an updated quality management review is completed, to include evaluation of medication management throughout the discussed patient’s admission, and disseminates findings to staff and service lines involved in the care of the patient.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Northport VA Medical Center Director ensures that the Office of General Counsel is consulted regarding the patient’s missed anticoagulation doses to determine if institutional disclosure to the patient’s family is appropriate per Veterans Health Administration Handbook 1004.08, Disclosure of Adverse Events to Patients.