The Inspector General finds that the hospital did not correctly count 3 deaths and attempted suicide
At least three patients at the Cincinnati VA Medical Center have died due to neglect of care, while another unsupervised patient attempted suicide between 2017 and 2020, the VA Inspector General reported this week in a report. difficult report on the operations of the establishment.
Officials did not properly document what happened to the four patients. Cincinnati VA officials also did not tell patients’ families what was happening to their loved ones, according to the 85-page report released Wednesday. Scroll to the bottom of the story to read the full report.
The overall system for examining the root causes of the hospital’s problems was also flawed, according to the report. Asked about the lack of data, a hospital official “said he did not fully understand that the series of ‘why’ questions should be documented … once these reviews are completed.”
The Inspector General’s review also revealed that the VA front office in Cincinnati, which has been on the move for at least five years, remains in turmoil. When Veterans Affairs investigators conducted a virtual site tour in July, three of the top four managers were working on an interim basis.
A post in charge of patient care “has been temporarily filled by four members of the staff of the medical center,” the report notes. “In addition, six different employees have held the interim Chief of Staff position since the position became vacant in May 2019.”
Overall, the report made 16 recommendations for improvement, some of which have already been made. The Inspector General’s latest report on the VA of Cincinnati, completed in 2017, made nine recommendations for improvement.
The Cincinnati VA Medical Center in Corryville supports nearly 45,000 patients in southwestern Ohio, northern Kentucky, and southeastern Indiana. Hospital spokesperson Todd Sledge said on Thursday that questions about the report should be sent to the Inspector General’s office in Washington, DC.The Inspector General’s office referred questions to the VA in Cincinnati, who did not respond on Thursday.
The Inspector General’s report reviewed hospital operations from 2017 to 2020. As part of this review, the Inspector General examines “sentinel events,” incidents or conditions that cause death or serious injury to patients. .
The Inspector General reported that when investigators requested to review sentinel events during those three years, “the head of patient safety and the head of quality management said the facility did not had identified no sentinel events during this period. “
But when investigators delved deeper into hospital records, they found “four cases that could have met the criteria for sentinel events.”
“Three of the four cases resulted in patient death: the first was related to prompt treatment for a critical laboratory value, the second was associated with a delayed transfer to a community hospital, and the third involved an invasive procedure. The fourth event involved an attempted act of self-harm by an unsupervised patient with suicidal thoughts, ”the report said.
The VA is to notify the families of loved ones affected in the sentinel events, but in those four cases, the inspector general said, there was no evidence of disclosure. When the Inspector General then reviewed three years of such required disclosures, “none were made in a timely manner and the related documentation in the electronic patient health record did not contain the required reasons for the delays.”
The Inspector General also found that in 2019, two deaths at the Cincinnati VA that occurred within 24 hours of admission “were not evaluated to determine whether a peer review was warranted.” This may have prevented the timely identification of inconsistencies in the practices of health care providers or the opportunity to identify systemic problems. “
The report said, “The head of quality management could not explain the lack of evaluation.”
Even the hospital’s patient care quality monitoring system had broken down, the inspector general said. In 2019, the hospital’s quality, safety and value (QSV) committee, responsible for monitoring patient outcomes, “did not systematically implement actions. This could have resulted in insufficient monitoring of patient safety and necessary improvements in the quality of care.
“The head of quality management said that a separate spreadsheet was kept to track actions, but it was not included in the QSV committee minutes or agenda.”