Healthcare Inspection: Alleged Quality of Care Issues and Privacy Violations, Battle Creek VA Medical Center, Battle Creek, Michigan

摘要

The VA Office of Inspector General, Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding quality of care issues and privacy violations at the Battle Creek VA Medical Center in Battle Creek, Michigan. We substantiated that an employee had an allergic reaction, and that epinephrine was administered incorrectly. Managers requested a review of the care that was given, and appropriate actions were taken. We could not substantiate or refute that acts of patient neglect occurred. However, we did find that the medical centers policy for reporting incidents was not followed or enforced. We substantiated that unit nurses had not been trained or determined to be competent on all defibrillator functions. We determined that not all unit staff were compliant with the medical centers basic life support training requirement. We could not substantiate or refute that unit nurses improperly interpret cardiac rhythms. Not all required staff had documentation of telemetry interpretation training. We could not substantiate or refute that the current number and levels of unit nurse staffing or the care delivery system was insufficient. We did find that NAs are required to administer gastric tube feedings, and this requirement is authorized by medical center policy.