|Title:||Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California|
|City/State:||Los Angeles, CA
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Hotline Healthcare Inspection
The VA Office of Inspector General (OIG) assessed allegations at the VA Greater Los Angeles Health Care System in California (facility) that community living center (CLC) nursing staff failed to (i) assess a resident who was complaining of pain; (ii) properly document assessments, reassessments, treatments, or interventions; and (iii) follow and implement a provider’s order related to transferring the resident to a higher level of care. The OIG also identified concerns associated with an institutional disclosure and inadequate care coordination.