Healthcare Inspection – Administrative and Clinical Concerns, Central California VA Health Care System, Fresno, California

OIG conducted a healthcare inspection to address concerns received from Congressman Jim Costa in 2014 regarding allegations from an anonymous complainant of Emergency Department (ED)-boarded patients’ length of stay, poor inpatient flow, and nurse staffing shortages at the Central California VA Health Care System (system), Fresno, CA. An anonymous complainant with similar allegations contacted the OIG Hotline in December 2013, July 2014, and February 2015. We requested system leaders respond to the allegations and in their May 2015 response, they acknowledged issues with ED-boarded patients’ length of stay, inpatient flow, and registered nurse staffing, and implemented an improvement plan with 15 actions. In January 2016, we conducted a review of system leaders’ progress after 6 months (July 1, 2015 through December 31, 2015) of implementing their action plans. We found that they did not implement 1 of the 15 actions: system leaders had not established written protocols to identify a process to transfer ED-boarded patients to available VA and non-VA facilities when acute inpatient beds were unavailable. In addition, the system’s policy that addressed the designated location for ED patient overflow did not identify criteria for ED-boarded patients who could be transferred to the Community Living Center. In the course of our review, we identified a patient whose adverse outcome illustrated many of the challenges associated with ED-boarded patients who need to be transferred due to the lack of available inpatient beds. The patient died after a prolonged transport on the maximal dose of a medication generally used in critical care. We made eight recommendations.