Leadership, Clinical, and Administrative Concerns at the Charlie Norwood VA Medical Center, Augusta, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess anonymous allegations involving multiple quality of care and leaders’ failures at the facility. Many of the allegations were largely unfounded; however, the OIG identified concerns including clinical staff members who did not feel supported by the leadership team and who described communication styles that were not consistently viewed as professional, positive, or oriented toward problem-solving. The hiring process was inefficient and problem-prone, and nurse staffing in the critical care unit (CCU) was problematic. Communication about, and understanding of, certain facility policies was inadequate. The OIG team identified deficits in completion and documentation of CCU nurse competency assessments, and found that the facility did not respond adequately to a 2018 sentinel event. Poor nursing morale was attributed to inadequate nurse staffing levels, guidance, and accountability. Emergency department nurse staffing issues had not been adequately addressed. The OIG identified other emergency department issues related to security, availability of laboratory services, and unclear policies regarding patient transfers that potentially placed emergency department patients at risk. Communication surrounding the use of a connecting bridge between the facility and Augusta University Medical Center was a confusing and contentious problem for staff of both institutions. Despite the facility’s complex designation, various clinical services were periodically reduced or unavailable. The OIG made 27 recommendations involving communication, hiring processes, staffing in the CCU and emergency department, policy development and communication, nurse competencies, nasogastric tube procedures, provider privileges, and emergency department security, among other areas.