Coordination of Care and Employee Satisfaction Concerns at the Community Living Center, Loch Raven VA Medical Center, in Baltimore, Maryland

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding management and patient safety at the Community Living Center (CLC). The complainant alleged that CLC managers discouraged incident reporting, coached staff on how to talk to residents or the resident’s personal representative following adverse events, and made staff fearful of retaliation for reporting concerns. Allegations also included inadequate staffing and oversight for resident care, mismanagement of laboratory specimens and medication delivery, and regulation of environmental temperatures. The OIG identified additional concerns related to employee dissatisfaction and laboratory staff’s failures to notify healthcare providers of critical laboratory results. The OIG did not substantiate managers discouraged incident reporting, inappropriately coached staff, or made staff fearful of retaliation for reporting concerns. System leaders acknowledged persistent staff dissatisfaction could have affected resident care. Although actions were taken to improve operations, unresolved issues related to employee satisfaction persisted. However, the OIG concluded the system maintained adequate nurse and provider staffing for resident care. The system exceeded Veterans Health Administration requirements for evaluating nurse staffing. Laboratory specimen handling led to falsely elevated potassium results and unnecessary treatment. Laboratory staff failed to thoroughly investigate and resolve the cause of inaccurate results. Additionally, the OIG found providers were inconsistently notified of critical laboratory results. CLC medication deliveries were also delayed. Although the causes for delays were undetermined, the lack of an on-site pharmacy likely contributed. During the inspection, the System Director announced plans for a pharmacy at the CLC. The OIG did not substantiate additional allegations of an inability to regulate environmental temperatures. Facility and engineering staff provided timely responses to periodic temperature issues. The OIG made five recommendations to the System Director related to CLC employee satisfaction, laboratory specimen handling, investigation of laboratory concerns, critical laboratory result notifications, and medication delivery.