Inadequate Community Living Center Processes and Training at the West Texas VA Health Care System in Big Spring

The VA Office of Inspector General (OIG) conducted an inspection at the West Texas VA Health Care System in Big Spring (facility) to assess an allegation that community living center (CLC) nursing staff did not respond when a patient experienced a medical emergency. The OIG did not substantiate that facility CLC nursing staff failed to respond to the patient’s medical emergency. The OIG found that although CLC nursing staff responded, the CLC registered nurse was unaware of the facility’s medical emergency policy and, as a result, failed to follow policy by not obtaining the automated external defibrillator (AED) and calling 911 immediately to activate the emergency response. Facility leaders failed to define CLC staff responsibilities when responding to medical emergencies in the CLC and had not provided mock code training to CLC nursing staff since October 2019. At the time of the patient’s medical emergency, a bag-mask device used to assist patients with breathing was not available and staff needed to be trained on how to use an AED. The OIG could not determine if the lack of mock code and AED training and the lack of equipment affected the outcome for this patient. The CLC registered nurse failed to document relevant patient care information during and after the patient’s medical emergency. The OIG determined that the documentation failure did not affect the outcome for this patient, but complete and timely documentation is vital to accurate health information. The OIG made three recommendations to the Facility Director related to ensuring CLC nursing staff are trained on roles and responsibilities when responding to medical emergencies, mock codes are completed within the CLC to include all CLC nursing staff, and all CLC clinical staff meet electronic health record documentation requirements.