Healthcare Inspection - Alleged Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California

The VA Office of Inspector General Office of Healthcare Inspections evaluated the validity of an allegation regarding patient neglect and abuse at the VA Central California Health Care System (the system), Fresno, CA. The complainant alleged that a patient developed bedsores (pressure ulcers) due to neglect and abuse while an inpatient on the system’s medical units and as a resident in the community living center. We did not substantiate the allegation. We found that the patient developed pressure ulcers while being treated by the system as well as subsequent pressure ulcers that developed when not an inpatient. However, we concluded that these were not the result of neglect or abuse but more likely the result of his debilitated, catabolic state, and the insertion of a Foley catheter used in the treatment of life-threatening urosepsis. We determined that the patient was assessed for skin breakdown and pressure ulcer interventions were initiated by the system in a timely manner. We made no recommendations.