Report Summary

Title: Nurse Staffing, Patient Safety, and Environment of Care Concerns at the Community Living Center within the San Francisco VA Health Care System in California
Report Number: 20-00005-271 Download
Issue Date: 9/29/2020
City/State: San Francisco, CA
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) evaluated allegations that facility leaders failed to address nurse staffing shortages yet continued to accept resident admissions and that the shortages contributed to adverse events, environment of care concerns, and infection control issues. The OIG further assessed allegations that the Community Living Center (CLC) did not have 24-hour housekeeping aides available, was dirty and infested with flying insects, CLC staff did not wash their hands, the CLC was quarantined more than two times during a 12-month period, a contracted staffing company (registry agency) was not meeting the requested number of nursing assistants (registry staff), and registry staff did not have access to residents’ electronic health records (EHRs).

The OIG substantiated that facility leaders failed to address CLC nurse staffing shortages yet continued to accept admissions. The OIG was unable to determine if insufficient CLC staffing levels led to adverse events. However, the OIG identified a higher potential for an adverse clinical outcome related to a missing resident. The facility missed an opportunity to further analyze the event.

Facility leaders reduced the number of operating beds without VHA authorization. Managers increasingly relied on registry staff, but the registry agency inconsistently supplied the requested number of staff. The Staffing Methodology Coordinator had insufficient knowledge and used inaccurate staffing targets.

The OIG substantiated that 24-hour Environmental Management Service was not available; CLC staff were not consistently meeting the facility hand-hygiene compliance goal; one or both CLC floors closed to admissions and visitors between 2018 and 2019, but CLC staff followed identified processes to minimize additional exposures; and registry staff did not have access to EHRs and could not document care.

The OIG did not substantiate that the CLC was dirty but substantiated the presence of flying insects.

The OIG made ten recommendations to the Facility Director.