Healthcare Inspection – Pressure Ulcer Prevention and Management, VA New York Harbor Healthcare System, New York, New York

OIG conducted a healthcare inspection to assess allegations regarding pressure ulcer prevention and management at the Brooklyn and Manhattan campuses of the VA New York Harbor Healthcare System (system), New York, NY.  The timeline of events and allegations were:  in 2014, a patient developed pressure ulcers following admission to the system, which were not appropriately managed by clinical staff.  Initially, OIG’s Hotline Division requested that the system conduct a review of the complainant’s allegations and submit a response.  We determined the response to be insufficient.  We subsequently referred the matter to the Veterans Integrated Service Network (VISN) for a response and included specific questions for VISN leadership to address.  In 2015, another patient developed pressure ulcers, which were not appropriately managed by clinical staff.  In April 2016, we determined the second response regarding Patient A was insufficient and after reviewing a similar complaint from Patient B, we initiated this healthcare inspection. We substantiated that Patient A developed pressure ulcers that subsequently worsened following admission, and clinical staff failed to implement timely and appropriate interventions.  We substantiated that Patient B developed pressure ulcers following admission.  However, we found that clinical staff timely identified and took steps to address Patient B’s pressure ulcer, which healed prior to his initial discharge from the system.  We noted that clinical staff skin care documentation was incomplete and inconsistent for both Patients A and B.  To further evaluate the system’s quality of pressure ulcer documentation, we reviewed electronic health records of acute care patients with pressure ulcers who were discharged from December 1, 2015 through May 31, 2016, and January 2017.  We identified noncompliance with requirements for pressure ulcer prevention and management-related documentation.  Since the time of our onsite visit in late June 2016, some issues with the quality of pressure ulcer documentation persisted.