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Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center, Augusta, Georgia

Report Information

Issue Date
Report Number
19-08296-118
VISN
7
State
Georgia
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
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted this healthcare inspection to respond to allegations related to inadequate nurse staffing and nurse-to-patient ratios in the Critical Care Unit (CCU) purportedly resulting in poor quality of care, which included the development of pressure ulcers, inadequate cardiac and respiratory care, and intravenous medication management failures. Lack of consistent documentation prevented the OIG from determining whether nurse staffing contributed to many of the conditions outlined in the allegations. The CCU daily nurse assignment sheets did not consistently document which bed a patient occupied or the nurse-to-patient assignment. The OIG identified noncompliant facility practices and other deficits that contributed to care management challenges and increased risk for poor clinical outcomes. The facility failed to designate a committee, required by Veterans Health Administration (VHA) and its own policies, to develop, implement, monitor, and evaluate the Pressure Ulcer Prevention Program. Facility staff with relevant wound care knowledge met periodically as the Skin and Wound Care Committee and provided pressure injury data to other committees, but there was limited evidence of analysis, action, or follow-up. Additionally, some CCU nurses did not know about the facility policy requirement to initiate wound care consults for patients at high risk for pressure injuries. Facility and tele-intensive care unit (ICU) staff also did not immediately recognize and respond to a life-threatening arrhythmia, which may have contributed to a patient’s death. Other OIG-identified deficits related to respiratory care, sitter availability, and medication management. The OIG made recommendations to the Facility Director regarding compliance with VHA and local requirements for pressure injury prevention and management including nursing documentation. Other recommendations focused on tele-ICU and cardiac monitoring, the respiratory care for a specific patient, processes for securing sitters when ordered, and CCU nursing staff assignment practices.

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 Charlie Norwood VA Medical Center Director ensures compliance with requirements outlined in Veterans Health Administration and Charlie Norwood VA Medical Center policy memorandums for the prevention and management of pressure injuries, including nursing documentation requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Charlie Norwood VA Medical Center Director ensures Critical Care Unit nursing staff receive ongoing training to manage patients at risk for developing pressure injuries.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Charlie Norwood VA Medical Center Director evaluates tele-ICU services, and makes changes as needed to ensure cardiac-monitored patients receive safe care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Charlie Norwood VA Medical Center Director ensures that a review to evaluate the circumstances related to Patient 8’s respiratory care is conducted and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Charlie Norwood VA Medical Center Director reviews current practices related to sitter availability when a physician orders a 1:1 sitter for Critical Care Unit patients and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Charlie Norwood VA Medical Center Director reviews current practices related to Critical Care Unit nursing staff assignments and takes action as indicated to support safe patient care when intravenous medications that require frequent dose adjustments are prescribed.