Report Summary

Title: Deficiencies in the Care of a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia
Report Number: 21-01048-154 Download
Report
Issue Date: 5/12/2022
City/State: Augusta, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted
Summary:

The OIG conducted a healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia (facility) to evaluate the adequacy of a patient’s outpatient care in the months prior to surgery and during preoperative and postoperative care. After surgery, the patient was admitted for orthostatic hypotension and physical deconditioning and placed under hospice care. The patient subsequently suffered alcohol withdrawal and declining health, and died in the intensive care unit.

Prior to the patient’s surgery, primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition, and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery. Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required.

The OIG also found the facility’s alcohol withdrawal protocol could be discontinued prior to the onset of a patient’s withdrawal symptoms. Medical-surgical unit nursing leaders did not have adequate quality controls or training in place to ensure the provision of safe and effective alcohol withdrawal nursing care.

The OIG made one recommendation to the Veterans Integrated Service Network Director to review the provider’s care of the patient. Nine recommendations were made to the Facility Director related to same-day care access, communication of test results and treatment plans, assigned surrogates, preoperative care, medical-surgical nurses’ patient care, Trendelenburg position usage and staff education, nursing competencies for alcohol withdrawal assessments and treatment, medical-surgical unit nurses’ quality control oversight, and the facility’s alcohol withdrawal treatment protocol.