Healthcare Inspection Post-Operative Care Case Review at the Lexington VA Medical Center, Lexington, Kentucky

The VA Office of Inspector General, Office of Healthcare Inspections reviewed allegations that poor post-operative nursing care in the intensive care unit led to complications resulting in a patient’s death at the Lexington VA Medical Center. The purpose of the inspection was to determine the validity of multiple allegations regarding specific nursing care incidents. We concluded the nursing care provided in the intensive care unit was appropriate. We substantiated one allegation that the pulse oximeter alarm was turned off during a nursing shift. During our review of the allegations, we found it difficult to navigate through nursing care flow sheets and progress notes in the medical record. We recommended that alarm systems in the intensive care unit remain activated and functional at all times. We also recommended the establishment of processes to improve medical record documentation of nursing care in the intensive care unit.