Healthcare Inspection – Community Nursing Home Program Safety Concerns, VA Northern California Healthcare System, Mather, California

At the request of Congressman John Garamendi, OIG conducted a healthcare inspection to assess allegations concerning patient safety in the Community Nursing Home (CNH) Program at the VA Northern California Health Care System (facility), Mather, CA. We substantiated that a patient was admitted to a locked CNH Alzheimer care center and told the complainant that he was being held against his will. However, we determined the patient’s placement was appropriate because a facility psychiatrist deemed the patient lacked decision-making capacity regarding his living situation and had demonstrated an inability to safely and independently live in the community. We also substantiated a delay in the patient receiving hearing aids with mitigating circumstances. We did not substantiate that a patient was given opioid medications against his wishes or that he was denied physical therapy. However, we identified a delay in the patient obtaining prosthesis care and confusion about the provision of his mental health care. We concluded that communication and collaboration between facility and CNH staff needed improvement. We did not substantiate that facility staff did not report an alleged financial abuse to Adult Protective Services; however the reporting was not completed timely. We substantiated Non-VA Care Coordination (NVCC) consult authorization delays for services. For the reviewed consults, the approval was timely; however, on average, NVCC staff took an additional 24 days before faxing the authorization approval to the CNH. We determined that program staff needed to monitor the NVCC process and that NVCC staff needed to timely fax authorizations to the CNH. We did not substantiate facility consult service delays. CNH patients generally received the requested services within 30 days. We substantiated that program registered nurses or social workers did not consistently comply with the required monthly or quarterly patient visits in CNH facilities. We determined that regular visits would have provided program staff opportunities to identify and resolve CNH patient-specific issues. We recommended that the Facility Director ensure (1) coordination of MH appointments between facility and CNH providers, (2) timely reporting of suspected elder abuse; (3) timely delivery of authorizations for consulted services to contracted CNH staff and coordination of NVCC appointments for CNH patients, and (4) visits by program registered nurses and social workers to CNHs are conducted as required.