Quality of Care Issues in the Community Living Center and Emergency Department at the Dayton VA Medical Center, Ohio

Report Information

Issue Date
Report Number
18-01275-89
VISN
10
State
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The OIG initiated an inspection to assess allegations regarding quality of care concerns at the facility with a focus on a patient’s care who transferred from the facility’s Community Living Center to the Emergency Department. The patient died in the Emergency Department. The OIG found delays and deficits in the patient’s care in the Emergency Department. An Emergency Department registered nurse failed to initiate cardiac and oxygen saturation monitoring. Deficiencies were also identified in medical decision making, provision of care, and handoff communication by an Emergency Department physician. The OIG determined that deficits in the physician’s practices were not limited to this case and shared these concerns with facility leaders. The physician was placed on a summary suspension and a management review of the physician’s practice was conducted, resulting in identification of “significant recurrent concerns” with the physician’s management and documentation. The facility’s Clinical Executive Board revoked the physician’s privileges. The physician appealed the decision. The VA Disciplinary Appeals Board overturned the physician’s removal from service; however, the physician subsequently resigned. The OIG identified concerns related to the facility’s quality management processes; the facility established a new standard for initiating management reviews to address those concerns. The OIG did not substantiate that the Emergency Department registered nurse was involved in additional patient deaths or that Emergency Department night-shift staffing was inadequate. Implementation of Emergency Department standing orders was inconsistent, and facility staff incorrectly destroyed a focused professional practice evaluation. Thirteen recommendations were made related to provider training, policy concerning transitions of care, standing orders, monitoring of critically ill patients, peer review training, Peer Review Committee documentation, leaders’ responses to identification of care concerns, Emergency Department supplies, bar code medication administration compliance, and document management procedures.

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 Dayton VA Medical Center Director identifies facility resources and other means for provider education and training to strengthen skills when deficiencies in care are identified during peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures that Peer Review Committee meeting minutes document reasons for changes to peer review levels, and that changes are consistent with its review of relevant aspects of clinical care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures review of procedures to make certain gastroenterology staff coordinate care with referring providers and provide staff training on care coordination procedures as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director makes certain that Community Living Center staff utilize the Situation, Background, Assessment, and Recommendation communication tool and document transfers to the Emergency Department in accordance with Dayton VA Medical Center policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director considers consolidating Medical Center policies related to patient transfers and transports to and from the Emergency Department into one policy to provide clear guidance to staff to effect timely transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures consistent implementation of standing orders in the Emergency Department.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director verifies policies and procedures are in place for monitoring of critically ill patients to track deterioration and need for intervention in the Emergency Department and during transport, and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures that handoff communication between Emergency Department providers is accurate and documented in the electronic health record during transitions in care in accordance with Dayton VA Medical Center policy, and compliance is monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures review of results from the revision of the Dayton VA Medical Center policy on threshold for peer review findings to trigger management reviews in order to confirm the revised policy is appropriately sensitive to identify provider practice issues that constitute patient safety concerns, and revise the policy if needed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director confirms all code carts in the Emergency Department are processed and secured consistent with Dayton VA Medical Center policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures Emergency Department supplies are secured and maintained consistent with Dayton VA Medical Center policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director ensures continued monitoring and compliance with bar code medication administration policy in the Community Living Center.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Dayton VA Medical Center Director reviews document management procedures for professional practice evaluations and takes actions as needed to comply with the VA Records Control Schedule.