Northport, NY VA
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....At the request of Northport Medical Center Director, the Office of Inspector General began an investigation into clinical concerns regarding the VAMC’s Nursing Home Care Units. In January 1998, the Office of Inspector General’s (OIG), Office of Investigations asked the Office of Healthcare Inspections (OHI) for assistance in exploring allegations of possible patient abuse and neglect in Nursing Home Care Units (NICO) at the Department of Veterans Affairs Medical Center (VAMC) Northport, New York.
On February 2, 1998, at the Medical Center Director’s request, an OHI inspector made a preliminary visit to the facility to assess the concerns of the senior management team regarding patient care in the NHCU. OHI inspectors and OIG investigators conducted an unannounced visit of NHCUs and a Psychiatry Ward from March 1, to March 4, 1998. The OIG team identified numerous clinical leadership, quality management, and nursing care practices and behaviors in these areas that impair patient care and medical center operations. OHIO organized and categorized the discrepancies into the following areas:
Systems issues that prevented long-term care managers from performing their duties;
Inadequate environmental management and patient safety practices; Inadequate quality management and risk management oversight;
Medication error under-reporting;
Management of Disturbed Behavior and Annual Training for Restraint and Seclusion Procedures Are Inconsistent Inadequate administrative investigation procedures;
Non-reporting of possibly serious patient incidents;
Overt patient abuse and neglect; Inadequate patient assessment and treatment planning;
Inconsistent nursing procedures;
Inaccurate pressure sore evaluation and reporting;
Falsification of nursing care documentation;
Questionable patient feeding and nutrition assessment practices;
and Some employees inattentive to patient care Based on the scope of these issues, OHI elected to conduct a more comprehensive inspection. In order to facilitate such a broad inspection, OHI recruited a team of Veterans Health Administration (VHA) healthcare professionals who are recognized experts in long-term care, psychiatry, and nursing management to assist and supplement OHI inspectors’ efforts....
CONCLUSIONS
Numerous systems deficiencies impeded long-term care (LTC) managers’ ability to perform their duties. Ineffective management practices were prevalent on the LTC wards, and throughout the medical center. Weak and ineffective management practices led to widespread distrust among employees and to employees’ fear of retaliation and reprisal for reporting concerns or allegations. Communication within the organization is often indirect or does not reach employees who have the authority to resolve problems. Therefore, failure to report problems became normal behavior.
NHCU wards are adequately staffed. However, inadequate staff utilization and inequitable workload assignments led to employees’ and patients’ perceptions that wards have inadequate nursing staffing.
The risk management (RM) program is not adequately organized to decrease the likelihood that potentially harmful patient care errors will occur. The Quality Assurance and Improvement (QA&I) Coordinator and Risk Manager do not provide the support that clinical managers need to ensure patient safety and facilitate performance improvement. The Medical Center’s quality management program did not provide comprehensive analysis, tracking or trending as required by JCAHO and VHA standards. Quality/Risk Management did not adequately disseminate information to clinicians. While numerous performance improvement activities were noted within the medical center, the system lack an effective flow of information to report these improvements.
Medication administration procedures do not ensure that patients receive needed drugs. Nurses do not always initial continuing medication records (CMR) to certify that they administered patients’ drugs. Some nurses circle the dosing entry, denoting that they did not administer the drug, but fail to record an explanation for not administering the medication on the CMR, as required. Senior managers were aware of, but did not appear to have initiated inquiries into two incidents of alleged patient abuse, that occurred in March and April 1998. Many issues that executive managers ordered to be fully investigated did not appear to merit full administrative investigations. Investigations frequently did not comply withheld policy, nor was there any uniformity in the investigative process. Local investigators did not always follow their charge, base conclusions on evidence, or make appropriate recommendations. There is no evidence to demonstrate that managers implemented, or followed up on investigators’ recommendations.
The use of restraint and seclusion is integrated into the overall management of crisis intervention in the psychiatric areas. Tracking and trending data of restraint and seclusion usage is available to VAMC psychiatric treatment teams when needed. LTC nursing employees do not make 2 hourly patient observation rounds as required by local policy. This presented a potential danger to restrained patients.
NHCU clinicians do not always adequately assess patients at the time of admission, following an accident/incident, or at the time of required 60-day reviews. Monthly RN reassessments occur; however nurses need to strengthen documentation to more accurately reflect the residents’ conditions. Interdisciplinary Care Plans do not always clearly reflect residents’ problems or needs, individualized interventions, or realistic, measurable goals. Interdisciplinary participation in assisting patients, to achieve treatment goals is minimal. The facility has a program to assess patients for the risk of developing pressure sores but it is not always effective. Nurses complete pressure sore assessment forms weekly without visually assessing the patient’s skin, until a long-standing sore is ultimately discovered. Nurses who administer medications also certify that all treatments are completed even though they may not personally complete or witness the treatments. Nursing employees do not consistently record patients' activities of daily living (ADL).
LTC nursing assignments on the 12:00 mid-night to 8:00 a.m. tour-of-duty were inequitably distributed. Most NHCU patients appeared to be clean and well-groomed but some were unshaven.
Nursing employees on one psychiatry ward allowed several patients to go to sleep at night wearing street clothing and shoes, during an April 7, 1998 3:00 a.m. to 5:30 a.m. inspection.
....Five management deficiencies adversely affected medical center operations. These deficiencies included systems deficiencies, ineffective communications, inadequate staffing distribution and assignments, adversarial union relationships, and inequitable distribution of performance awards...
....LTC nursing employees asserted that they frequently lacked basic operating supplies and logistic support to provide adequate patient care. We confirmed that, prior to the March 1998 OHI site visit, linen shortages were commonplace, especially on the weekends, and other patient care supplies were frequently not available....
....The Chief of Nursing Service (CNS) acknowledged that she had not visited the NHCU for more than 6 years...
...inspectors noted a strong odor of stale urine in most hallways on NHCU wards I and II. Inspectors also found that NHCU II was filthy and unkempt. Several patients’ dresser drawers were open, creating potential tripping hazards; baseboards were dirty, several patients’ urine catheter bags were lying on the floor; and intravenous and tube feeding machines, bed rails, and wheel chairs were covered with grime and excreted body fluids. The nurses’ break room table and refrigerator were filthy and cluttered; patients’ snacks were opened and left at bedsides; open and out-dated patient snacks were sitting in a dirty refrigerator; and the clean utility room had cobwebs on the ceiling, and papers on the floor. Furniture in NHCU wards I and II was purchased in the late 1980s when the building was opened. With the large number of total care and incontinent residents, urine evidently soaked into many of these aging mattresses and chairs, leaving a strong noxious odor....
....Inspectors learned that a small, contained fire had occurred in the designated outdoor, screened smoking area on Unit 8A (locked psychiatry unit) on December 5, 1997. The fire was directly associated with patients’ cigarette smoking. Corrective action was taken to prevent similar incidents. However, fresh cigarette burns were found on the ward furniture and bedding suggested that patients’ were still smoking on the unit. Inspectors performed an unannounced inspection on the ward on April 9, 1998, and found smoking materials, i.e., matches, cigarettes, and lighters, as well as razors inpatients’ bedrooms..
There were several improper clinical care actions and behaviors that adversely affected patient safety and the quality of patient care. The issues include patient abuse, inconsistent or inadequate documentation, inadequate patient assessment, improper evaluation and reporting of pressure sores, and questionable patient feeding and nutrition assessment practices...
...During a physical inspection of the LTC wards, inspectors found several patients lying in urine-soaked pajamas. Several patients could not reach their call lights. These patients told us that it took a long time for nursing employees to come to their aid. One patient had a Range of Motion (ROM) Exercise Sheet by his bed, however he told inspectors that no one had helped him to perform the exercises.
Northport's senior management team requested the OIG team to review allegations regarding specific patient incidents of abuse and subsequent boards of investigation. In one incident, management believed that abuse had occurred, although the board could not substantiate this conclusion. The OHI team concluded that patient abuse had occurred. The fact that this patient laid in one position for several hours, apparently without any nursing assistance, we believe represents patient abuse. This patient specifically asked OHI not to further investigate the incident because he feared retaliation by some employees. Facility managers are aware of the patient’s concerns and assured OHI that the patient will be appropriately monitored.
Inspectors reviewed monthly NHCU staff meeting minutes from 1996 to May 1998. The minutes show that meeting participants discussed patient abuse concerns during 5 of the 27 monthly meetings. The PAC and the ACNES/EC signed all of these meeting minutes and forwarded them to the Nursing Service’s Office of Quality Management. Both the ACNS/EC and the Nursing Quality Manager, who is directly responsible to the CNS, should have informed the Chief Nurse of these patient abuse concerns. The ACNS/EC told inspectors that she discussed unit issues, including concerns of possible patient abuse, during the Chief Nurse’s monthly meeting with the PCCs, and expanded role nurses. The ACNS/EC also told inspectors that she had discussed specific incidents of alleged abuse with the CNS. The CNS acknowledged that since QA patient abuse data was not routinely available to nursing, the expectation was that the Nursing Service Office of Quality Management would do the follow-up, but she could not provide any evidence that necessary follow-up was ever done...
...There was evidence that patient abuse occurred. In one incident a nursing employee turned a patient onto his abdomen during the night, and left him in that position for many hours. The patient was unable to turn himself due to severe contractions, and subsequently sustained abrasions to his face and shoulder. A BOI did not show patient abuse.
OHI disagrees with the investigator’s conclusions. The fact that this patient laid in one position for several hours, without nursing assistance, we believe represents patient abuse. NHCU medical records lack documentation of adequate patient assessment and treatment planning. The records lacked any evidence that clinicians adequately assess patients at the time of admission, following an incident, or at the time of required 60-dayreviews. Senior managers need to ensure that clinicians adequately assess patients and properly record these actions, and properly record treatment planning.
Nursing employees do not consistently make rounds during irregular tours-of-duty as required by local nursing policy. Nursing employees gave a variety of responses when we asked how often they conducted nursing rounds, none of which complied with local nursing policy. Senior managers need to ensure that the Chief Nurse develops consistent nursing procedures for patient observation rounds, with checklist verification by employees who conduct the rounds.
Nurses complete pressure sore assessment forms each week, but apparently do not consistently visually assess the patients’ skin until long-standing sores are discovered. Senior managers need to ensure that clinicians report, stage, track and document pressure sores in the medical records.
Nursing employees follow questionable patient feeding and nutrition assessment practices. The unit dietician had only been assigned to the unit for a short time and was in the process of establishing monitors to trend data on weights and other nutrition assessment practices. The medical center had instituted a volunteer patient-feeding program, which needs additional volunteers. Senior managers need to ensure that clinicians establish systematic procedures for patient feeding and nutrition assessmentpractices.
Northport Nurses 1999 VA OIG Report
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