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

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.