Quality of Care Concerns in the Hemodialysis Unit at the Wilmington VA Medical Center, Delaware

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding two patients’ care in the Hemodialysis Unit at the Wilmington VA Medical Center in Delaware. Although the OIG was unable to substantiate that the care received in a dialysis unit contributed to a patient’s death, the inspection revealed quality of care issues. The dialysis unit staff did not obtain the patient’s blood glucose level prior to dialysis as ordered and did not follow policy on the urgency required for treating critically high values. Staff failed to clinically assess this patient before release, even though the patient had received non-scheduled medications. Among other concerns, staff administered medication after a verbal, rather than written, order and failed to follow a change to dialysis orders. The patient was found deceased in a car on facility grounds. VA police violated policies and procedures that could have addressed the patient’s car being in an illegal parking spot for more than 17 hours, where the patient was found deceased. The OIG also identified nursing documentation issues, staffing difficulties, and personnel conflicts. Due to unstable nurse management, new policies had not been developed and implemented. Facility leaders and mid-level managers did not assign a Safety Assessment Code or conduct a Root Cause Analysis to look at process or system issues after this patient’s death. The OIG did not substantiate that a nurse incorrectly switched a valve on a machine used for the second patient’s dialysis. The OIG substantiated that dialysis staff initiated CPR on the patient. The patient recovered, but OIG identified concerns related to the emergency response. VA concurred with the 14 recommendations on policy and processes, verbal medication orders, code blue documentation and reporting, and police policy.