Healthcare Inspection – Patient Safety on a Critical Care Unit, Malcom Randall VA Medical Center, Gainesville, FL

OIG reviewed allegations regarding a nurse’s practice on a critical care unit at the Malcom Randall VA Medical Center in Gainesville, FL. We substantiated the allegations that the registered nurse (RN) falsified documentation and did not administer insulin as ordered for a patient. We did not substantiate the allegation that the RN was practicing medicine without a license or that patient care was not documented until the end of a shift. We did not substantiate the allegation that the RN failed to provide pain medication for a patient; however, the RN did not provide pain medication as ordered nor adhere to local policy for pain management. We substantiated the allegation that previous concerns about the RN were reported to the Nurse Manager (NM), but not that nothing was done. However, we found that there was a pattern of quality of care issues associated with the RN, and that the NM did not address the issues following appropriate managerial protocol. We recommended that the System Director follow through with Administrative Investigative Board recommendations, and request that Regional Counsel evaluate relevant documents to determine if criteria are met to report the RN’s actions to state licensure governing boards. The Veterans Integrated Service Network and System Directors agreed with the findings and recommendation and provided an acceptable action plan.