Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama

The Office of Inspector General (OIG) assessed allegations at Tuscaloosa VA Medical Center (facility) that facility and community living center (CLC) leaders failed to address CLC safety and security issues, and that facility leaders failed to fill key positions, utilize unused space, and ensure environment of care and grounds provided a safe setting. Facility leaders failed to address CLC safety and security issues resulting in a resident’s elopement. The OIG found a 2018 quality improvement recommendation to install an alarm system was not implemented until November 2021. The OIG identified concerns regarding operability of CLC cameras, CLC outdoor security, and use of elopement risk alerts in residents’ electronic health records and determined these concerns likely contributed to, or failed to mitigate, resident elopements. Facility leaders failed to fill several key positions. Difficulty in recruiting candidates, lower salary levels, and challenging human resource processes were contributing factors. The OIG did not substantiate facility leaders failed to use available space. Although the facility had unused space, the OIG found the lack of use did not limit patient care. The OIG did not substantiate facility leaders failed to ensure the environment of care and grounds provided a safe setting. The OIG determined facility leaders did not inspect patient care areas and grounds per policy and due to multiple findings during the on-site visit and determined the facility’s environmental care rounds were ineffective. However, the OIG found the facility’s grounds were generally maintained and did not observe safety concerns that impacted patient care. The OIG made one recommendation to the Veterans Integrated Service Network (VISN) Director to ensure completion of VISN site visit recommendations. Nine recommendations were made to the Facility Director to assess CLC security; develop a plan for coverage recruitment, and retention of difficult to fill positions; and improve environmental care rounds.