|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|
|City/State:||San Francisco, CA
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Healthcare Inspection
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).