Deficiencies in Care at the Batavia Community Living Center Contributed to a Resident’s Death at the VA Western New York Healthcare System in Buffalo

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Date Issued

Thursday, July 31, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-02930-175

Report Description

The VA Office of Inspector General (OIG) conducted a healthcare inspection related to the care of a resident at the Batavia community living center (CLC), a part of the VA Western New York Healthcare System (system).

In late winter 2024, Resident A was admitted to the Buffalo VA Medical Center (VAMC) for combativeness, agitation, and confusion. After the resident’s dementia-related behaviors were controlled, the resident was admitted to the Batavia CLC and received 21 doses of injectable antipsychotic medications throughout the 23-day stay. On CLC day 20, the resident’s elevated fingerstick blood sugar level was not reported to a physician for treatment and on CLC day 23, the level was more than four times the system’s upper limit of normal. The resident was admitted to a community hospital, then hospice at the Buffalo VAMC, and died shortly thereafter.

The OIG substantiated that ongoing and cumulative deficiencies, including (1) physician and nursing staff management of Resident A’s dementia and diabetes and (2) nursing documentation of medication administration and nutritional intake, may have contributed to the resident’s preventable decline in health, which necessitated end-of-life care.

The OIG found similar deficiencies in care for a second resident and identified concerns regarding leaders’ response to clinical care deficiencies, including a failure to enter a patient safety report regarding Resident A’s elevated fingerstick blood sugar result on CLC day 20. Once aware of care concerns, system leaders’ response included temporarily removing the chief geriatric physician and initiation of clinical and administrative investigations. Further, the OIG identified deficiencies in provider staffing and nurse education that increase risk to patient safety and may have contributed to Resident A’s functional decline.

The OIG made 10 recommendations to the System Director regarding dementia and diabetes care, quality assurance performance improvement, and focused review of the chief geriatric physician’s care.

Report Type

Inspection / Evaluation

Location

NY
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/hotline-healthcare-inspection/deficiencies-care-b…

Open Recommendations

This report has 10 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The VA Western New York Health Care System Executive Director ensures that community living center staff complete behavioral notes and conduct behavioral rounds, consistent with system policies regarding behavioral health and administration of antipsychotic medications, monitors for compliance, and takes action as indicated.
02	No	$0	$0
The VA Western New York Health Care System Executive Director evaluates community living center nursing staff compliance with system policies regarding the administration of medications, and nursing documentation related to medication refusals, medical provider notification, and residents’ nutritional intake, and takes action as required.
03	No	$0	$0
The VA Western New York Health Care System Executive Director reviews the system policy regarding the use of antipsychotic medications in the community living center and considers aligning system policy with Veterans Health Administration’s dementia system of care recommendation to document risk-benefit discussions for all residents receiving pharmacological interventions for dementia-related behaviors.
04	No	$0	$0
The VA Western New York Health Care System Executive Director makes certain community living center staff comply with the system policy on fingerstick blood sugar testing, including documenting results and notification to the resident’s provider, and monitors compliance, taking action as indicated.
05	No	$0	$0
The VA Western New York Health Care System Executive Director reviews Batavia community living center laboratory processes and takes action as necessary to ensure timely completion of orders.
06	No	$0	$0
The VA Western New York Health Care System Executive Director ensures community living center staff enter joint patient safety reports and disclosures, as Veterans Health Administration guides and requires, and in support of high reliability organization principles, and monitors compliance.
07	No	$0	$0
The VA Western New York Health Care System Executive Director makes certain the community living center quality assurance performance improvement procedures adhere to Veterans Health Administration requirements, including the use of data to track effectiveness of quality assurance activities, and supports improvement in community living center nursing care.
08	No	$0	$0
The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.
09	No	$0	$0
The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.
10	No	$0	$0
The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.