Staffing, Quality of Care, Supplies, and Care Coordination Concerns at the VA Loma Linda Healthcare System, California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to nurse staffing and inadequate supplies. The OIG did not substantiate deaths occurred due to untimely patient transfers between the Emergency Department and inpatient units because of insufficient nurse staffing. Due to lack of documented evidence, the OIG was unable to determine if there were unsafe working conditions related to high patient-nurse ratios. The OIG did not find an increase in the number of adverse events January 1, 2016, through June 30, 2017, and was not able to make a correlation between the adverse events that did occur and nurse staffing issues. The OIG substantiated that the system had inadequate supplies including linens but had taken actions to improve the deficiencies. The OIG found that 35 percent of Emergency Department patients admitted to the system from August 1, 2016, through June 30, 2017, waited for four hours or more (boarders) to be transferred to their assigned units. Quality of care concerns were identified for five of 13 boarder patients that the OIG reviewed related to their not receiving the same level of care in the Emergency Department as they would have received in the assigned units. The OIG also identified deficiencies in the reporting of closed beds, accuracy of data collected in the Emergency Department, coordination of care between the system and the Robley Rex VA Medical Center, located in Louisville, Kentucky, for a traveling patient, and a potential patient safety issue related to a faulty Emergency Department surveillance camera. The OIG made 10 recommendations related to Emergency Department patient flow, accurate data collection, boarders’ level of care; coordination of care; completion of root cause analyses, and a review of two patients who suffered injuries after falls at the system.