Report Summary

Title: Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center, Augusta, Georgia
Report Number: 19-08296-118 Download
Issue Date: 5/12/2020
City/State: Augusta, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

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.