Review of Response to Changes in a Patient’s Condition and Quality Reviews at the VA Greater Los Angeles Healthcare System in California

Report Information

Issue Date
Report Number
24-03531-09
VISN
22
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.

The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.

Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.

Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.

The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2025

The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.