Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California

The VA Office of Inspector General (OIG) assessed allegations at the VA Greater Los Angeles Health Care System in California (facility) that community living center (CLC) nursing staff failed to (i) assess a resident who was complaining of pain; (ii) properly document assessments, reassessments, treatments, or interventions; and (iii) follow and implement a provider’s order related to transferring the resident to a higher level of care. The OIG also identified concerns associated with an institutional disclosure and inadequate care coordination. The OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. However, the OIG did not substantiate that other individual nursing staff members involved with the resident’s care failed to properly document the resident’s care. The OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but was unable to determine if this impacted the patient’s outcome. The OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC. The OIG made 10 recommendations to the Facility Director regarding confirmation of CLC nursing staff’s knowledge of policies related to nursing practices, documentation, pain assessments, verbal orders, Joint Patient Safety Reports, administrative reviews, and quality assurance reviews; a review of hand-off communications; the need for peer reviews specific to the resident’s care and CLC admission processes related to respiratory therapy equipment; completion of action items identified in the Corrective Action Plan and an institutional disclosure.