The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in a facility CLC and required surgery for a hip fracture sustained during the fall. The OIG did not substantiate that the patient’s fall was caused by inadequate fall precautions or that the patient’s death was caused by abuse or neglect. The OIG substantiated that the patient did not receive anticoagulation injections to prevent blood clots following surgery for hip fracture per facility protocol. The OIG did not substantiate that the failure to receive three of the four doses of anticoagulation medication during the hospital stay contributed to the patient’s death. The OIG was unable to substantiate or not substantiate that a staff member who performed one-to-one observation of the patient failed to provide proper observation during the shift when the patient died, because the OIG was unable to resolve discrepancies between facility documentation and staff interviews. The OIG did not substantiate that the CLC Nurse Manager received complaints about staff behaviors that negatively impacted patient care and failed to take corrective action. The OIG did not substantiate that facility leaders or managers tried to cover up the circumstances surrounding the patient’s death. However, the OIG determined that the missed anticoagulation medication doses were not addressed in the facility’s quality management review of the patient’s care. The OIG made three recommendations related to reviewing the accuracy of 24-Hour Observation Flow Sheets, conducting an updated quality management review of the patient’s case, and consulting with the Office of General Counsel about missed anticoagulation doses and institutional disclosure to the patient’s family.
Northport, NY
United States
