Healthcare Inspection - Alleged Quality of Care and Communication Issues, Northport VA Medical Center, Northport, NY

OIG reviewed five allegations regarding a patient’s fall at the Northport VA Medical Center. Due to insufficient documentation, we were unable to confirm or refute the allegation that the staff member assigned to monitor the patient was not present when the patient fell. We also did not substantiate the allegations that the facility did not perform adequate tests after the patient’s fall and that a surgical stapling procedure was performed at the patient’s bedside. We substantiated the allegations that the patient did not receive effective and timely pain management and that the facility did not appropriately disclose clinical information and respond to the family’s complaints. We recommended that the Medical Center Director strengthen processes to ensure that documentation for one-to-one monitoring of patients is accurate, the facility reassess the incident reporting process for effectiveness, the facility implement procedures to ensure that facility staff comply with VHA pain management policies and VHA and local clinical disclosure policies, and that facility responses to patient and family complaints are timely and facilitate resolution. The Veterans Integrated Service Network and Medical Center Directors agreed with the findings and recommendations and provided acceptable improvement plans.