Healthcare Inspection Alleged Quality of Care Issues Wilkes-Barre VA Medical Center Wilkes-Barre, Pennsylvania

The purpose of the review was to determine the validity of the following allegations: (1) the third lead wire was not placed during the implantation of a replacement pacemaker, as planned, (2) a post-operative surgical site infection was misdiagnosed, causing a delay in treatment, (3) the patient advocate failed to respond to a request that the surgeon not be assigned to the patient during a subsequent readmission (4) clinicians prematurely discharged the patient to a community nursing home, and (5) the medical center provided substandard care because of unqualified nurses and physicians and insufficient nurse staffing. We did not substantiate the allegations. We concluded that the patient received appropriate care and was properly discharged to the nursing home setting. We also concluded that the patient advocate responded appropriately. We determined that the physicians and nurses practiced in a competent manner and that the nursing units were adequately staffed. However, we concluded that communication and documentation could be improved to ensure a clear understanding of the plan of care by the patient and family. We recommended that the Veterans Integrated Service (VISN) Director require that the Medical Center Director ensures that providers on this case improve communication with patients and family members to ensure that instructions and plans of care are clearly understood and that they document instructions, plans, and patient and/or family member understanding in the medical record. Since management had already addressed the issue, we consider this recommendation closed.