Review of Response to Changes in a Patient’s Condition and Quality Reviews at the VA Greater Los Angeles Healthcare System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.

The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.

Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.

Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.

The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.