Healthcare Inspection Hemodialysis Nursing Care Issues at the John Cochran Division St. Louis VA Medical Center St. Louis, Missouri.

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding nursing care issues in the hemodialysis (HD) unit of the John Cochran Division of the St. Louis VA Medical Center (STLVAMC), St. Louis, Missouri. A complainant alleged that a licensed practical nurse (LPN) did not provide appropriate care to two HD patients, resulting in their need for emergency care. The complainant further alleged that the HD unit had nursing leadership issues that affected patient care. We substantiated that the LPN did not recognize and report changes in the condition of a patient who was somnolent and unresponsive at the end of his HD treatment. That patient required emergency medical treatment and died the next day. We did not substantiate that the LPN provided less than standard care for the second patient and continued HD treatment despite the patients report of chest pain. The patient had a history of chest pain for several days, and a physician had cleared the patient for HD, attributing the pain as musculoskeletal and not cardiac. The LPN reported clinical changes to the charge registered nurse (RN) who assessed the patient, discontinued HD, and called the rapid response team to evaluate the patient. We did substantiate a lack of effective nursing leadership in the HD unit. Staff competencies were not completed, RN and LPN roles were not delineated, charge nurse responsibilities were not defined, and there was no policy for reporting events to the charge RN or physician. HD staff perceived that they suffered retaliation when they reported complaints against the LPN. HD nursing staff perceived changes in scope of LPN practice as punitive for all staff rather than taking disciplinary action for the one individual. However, based on state nursing regulations and local policy, we concurred that LPNs cannot perform independent initial nursing assessments. STLVAMC leaders became aware of HD concerns when they received a request for review and an action report from The Joint Commission. Although an action report was submitted, a root cause analysis (RCA) was not conducted to determine potential systems issues. We made six recommendations related to improving HD nursing assessments, delineating scopes of practice, developing unit specific competencies that include specific HD elements, measuring nursing quality of care, performing an evaluation of staffing in the HD, and complying with Veterans Health Administration requirements for conducting an RCA. The Acting VISN Director and STLVAMC Director concurred with the inspection results and recommendations.