Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center in Augusta, Georgia

Veterans Affairs Office of Inspector General (OIG) sent this bulletin at 05/12/2020 12:53 PM EDT

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Given VA’s need to focus on the COVID-19 response, the OIG has developed interim measures for releasing oversight reports. Accordingly, at this time, the OIG is generally releasing only those reports that are relevant to the COVID-19 pandemic, statutorily required, or that involve compelling circumstances related to the welfare of veterans, the safety of patients and VA personnel, or pose significant risks to VA resources. 

 

Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center in Augusta, Georgia discusses significant patient safety issues including events related to noncompliance with pressure injury policy, intensive care unit cardiac monitoring, and sitter availability for high-risk patients. The report was received and initially addressed by VHA prior to the March pandemic declaration. Publication is warranted so that other facility leaders and healthcare practitioners can be made aware of OIG-identified problems applicable to their own facility. Report release should not pose an undue burden on the facility or VISN as no additional related actions are being requested.

 

Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center, Augusta, Georgia
05/11/2020 08:00 PM EDT

The OIG conducted this healthcare inspection to respond to allegations related to inadequate nurse staffing and nurse-to-patient ratios in the Critical Care Unit (CCU) purportedly resulting in poor quality of care, which included the development of pressure ulcers, inadequate cardiac and respiratory care, and intravenous medication management failures. Lack of consistent documentation prevented the OIG from determining whether nurse staffing contributed to many of the conditions outlined in the allegations. The CCU daily nurse assignment sheets did not consistently document which bed a patient occupied or the nurse-to-patient assignment. The OIG identified noncompliant facility practices and other deficits that contributed to care management challenges and increased risk for poor clinical outcomes. The facility failed to designate a committee, required by Veterans Health Administration (VHA) and its own policies, to develop, implement, monitor, and evaluate the Pressure Ulcer Prevention Program. Facility staff with relevant wound care knowledge met periodically as the Skin and Wound Care Committee and provided pressure injury data to other committees, but there was limited evidence of analysis, action, or follow-up. Additionally, some CCU nurses did not know about the facility policy requirement to initiate wound care consults for patients at high risk for pressure injuries. Facility and tele-intensive care unit (ICU) staff also did not immediately recognize and respond to a life-threatening arrhythmia, which may have contributed to a patient’s death. Other OIG-identified deficits related to respiratory care, sitter availability, and medication management. The OIG made recommendations to the Facility Director regarding compliance with VHA and local requirements for pressure injury prevention and management including nursing documentation. Other recommendations focused on tele-ICU and cardiac monitoring, the respiratory care for a specific patient, processes for securing sitters when ordered, and CCU nursing staff assignment practices.