Widespread Failures in Response to Suspected Community Living Center Resident Abuse at the VA New York Harbor Healthcare System in Queens

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine whether leaders and staff followed required procedures related to suspected elder abuse of a community living center (CLC) resident at the St. Albans VA Medical Center in Queens, part of the VA New York Harbor Healthcare System (system). 

The OIG determined leaders and staff failed to follow procedures to report suspected abuse. A nursing assistant witnessed another nursing assistant allegedly abuse a resident but failed to immediately notify a supervisor, due to being “scared.” Nursing leaders and staff did not immediately ensure the resident’s safety, and did not report the suspected abuse to a unit social worker, VA Police, the resident’s family, and the New York State Department of Health. A nurse practitioner evaluated bruises on the resident and did not document a complete physical exam, consider whether the bruises were related to abuse, or inform the resident’s family. Staff described a culture of silence in the CLC in which staff generally did not report, or underreported, patient safety incidents due to fear of reprisal or administrative burdens. 

Leaders conducted two factfinding investigations into the alleged abuse; however, neither factfinding was thorough, which led to inaccurate conclusions. Factfinding 2 was completed approximately five months after the alleged abuse, exceeding a 14-day completion requirement. An accurate conclusion would have indicated the allegation of patient abuse was plausible and required system leaders to conduct an administrative investigation board. 

The OIG found additional reporting deficiencies related to other incidents of suspected resident abuse; insufficient staff training; substandard documentation by staff, which hindered reviews and investigations; and omissions in Veterans Health Administration and system abuse-related policies. 

The OIG made one recommendation to the Under Secretary for Health, who concurred in principle, and six recommendations to the System Director.