Deficiencies in Nursing Care and Management in the Community Living Center at the Coatesville VA Medical Center, Pennsylvania

The VA Office of Inspector General (OIG) initiated an inspection to assess allegations regarding deficiencies in nursing care in the Community Living Center (CLC). The OIG substantiated the allegation that a CLC nurse improperly left medication in a patient’s room. The inspectors conducted an observation of 35 patient rooms and did not find any medications left in rooms or hallways other than two creams on a bedside table. While the OIG was unable to determine the validity of many of the allegations due to a lack of information from the complainants or within the patients’ electronic health records, there were nursing documentation deficiencies identified in the CLC related to the allegations. These deficiencies included inconsistent documentation of compliance with medication order instructions, pain assessments and pain management plans, fall prevention and post-fall assessments, fall prevention measures (including inconsistent answering of call bells), and nursing wound prevention processes. The OIG made other findings not specifically related to the allegations, including failure to follow the approval procedure for a new hourly rounding form, ineffective implementation of a new procedure for nurse rounding, incomplete fact-finding reviews, inconsistent facility committee documentation, and inoperable CLC safety equipment. A contributing factor for the identified deficiencies was an outdated facility staffing policy that did not follow all Veterans Health Administration (VHA) staffing methodology requirements for calculating adequate levels. The OIG made nine recommendations addressing nursing processes including documentation of fall prevention and post-fall assessments, placement and use of call bells, wound prevention processes, medication administration, and pain assessments and pain management plans; compliance of rounding forms to facility procedures; establishment of fact-finding review processes; leadership committees’ tracking and monitoring of issues to resolution; checks that safety equipment used for transfers is operational; and staffing policy consistency with VHA requirements.