Alleged Quality of Care Issues in the Community Living Centers, Northport VA Medical Center, New York

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding quality of care issues in two Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated Patient A died at the facility after choking on food, but found insufficient evidence to attribute the cause of the choking to the lack of nurse staffing. The OIG substantiated the facility operator called the wrong code, leading to multiple responders, role confusion, and a delay in transporting Patient A to the Emergency Department. The OIG did not substantiate managers misrepresented the cause of death as cardiac arrest. OIG inspectors found inconsistent emergency medical response policies, post-code debriefings, and medical oversight and determined Patient A’s case warranted additional facility review. The evidence was insufficient for the OIG to substantiate or not substantiate whether patients were regularly left unsupervised while eating. The OIG did not substantiate one CLC lacked security due to malfunctioning door locks. The OIG substantiated a lack of consistent documentation of rounds but was unable to ascertain if this condition reflected an absence of completed rounds and decreased unit security. The OIG was unable to substantiate or not substantiate a lack of staff vigilance. The OIG substantiated Patient B’s wrists were bound together by a palm protector strap but did not find evidence to suggest an intentional act done by staff due to a lack of available nursing staff. The OIG did not substantiate that CLC nursing managers were often unavailable and failed to provide adequate response to unit issues. The OIG made eight recommendations to the Facility Director and one recommendation to the Veterans Integrated Service Network Director related to emergency medical response processes and policies, CLC meal staffing and delivery processes, safety rounds, and reviews of Patient A’s care.