Healthcare Inspection: Quality of Care Issues VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska and VA Central Iowa Health Care System, Des Moines, Iowa

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding the quality of care received by a patient at both the Omaha, Nebraska (system 1) and Des Moines, Iowa (system 2) VA Health Care Systems. The complainant alleged that: h While at system 1 a patient: (1) suffered a stroke that was unnoticed by the Intensive Care Unit (ICU) nursing staff, (2) did not receive assistance with his meals and other activities of daily living (ADLs) while on the general medicine unit, (3) did not receive rehabilitative therapy, (4) did not receive a scheduled pulmonary therapy treatment, (5) did not receive pain medication in a timely manner, and (6) had a substantial delay in receiving prescribed seizure medication by mail. While at system 2 the same patient: (1) did not receive assistance with his ADLs; and (2) did not receive speech therapy, and (3) was discharged abruptly without discharge planning.