Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California

Report Information

Issue Date
Report Number
21-03595-219
VISN
22
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
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. The OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. However, the OIG did not substantiate that other individual nursing staff members involved with the resident’s care failed to properly document the resident’s care. The OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but was unable to determine if this impacted the patient’s outcome. The OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC. The OIG made 10 recommendations to the Facility Director regarding confirmation of CLC nursing staff’s knowledge of policies related to nursing practices, documentation, pain assessments, verbal orders, Joint Patient Safety Reports, administrative reviews, and quality assurance reviews; a review of hand-off communications; the need for peer reviews specific to the resident’s care and CLC admission processes related to respiratory therapy equipment; completion of action items identified in the Corrective Action Plan and an institutional disclosure.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director confirms that a process is in place to ensure community living center staff have knowledge of policies pertaining to nursing practice and documentation in the community living center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director ensures all nursing staff assigned to the community living center have received training on the completion and documentation of all required elements for pain assessments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director verifies that community living center nursing staff demonstrate knowledge of the procedure for managing verbal and telephone orders and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director reviews the Greater Los Angeles Healthcare System hand-off communication policy to determine if changes are warranted to address the procedure for managing hand-offs, ensures understanding of policy by staff, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director verifies that community living center staff are aware of events warranting submission of a Joint Patient Safety Report and how to submit one.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director evaluates the circumstances surrounding the death of the resident and determines if peer reviews of relevant clinical staff are warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director ensures that community living center managers receive training on the types of reviews, including quality assurance and administrative investigations and when each is appropriate for use, and documents attendance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director ensures that actions identified in the Corrective Action Plan are tracked to completion.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director confirms that an institutional disclosure is completed and documented to share that an “opportunity for intervention(transfer to the Emergency Department) existed and was considered but not acted on, prior to the terminal event.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Greater Los Angeles Health Care System Director directs community living center leaders to review policy and admission processes to ensure respiratory therapy equipment needed in the care of a resident is in place at the time of admission.