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SALISBURY VA HOSPITAL KNEW OF TROUBLES IN 2001
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VA facility had received warnings about poor
care.
Background with backlinks here...
http://vawatchdog.org/07/nf07/nfMAR07/nf032907-7.htm
Story here...
http://charlotte.com/115/story/70272.html
Story below:
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VA troubles exposed in '01
Salisbury hospital had received warnings about
poor care
STELLA M. HOPKINS AND KAREN GARLOCH
shopkins@charlotteobserver.com
kgarloch@charlotteobserver.com
The Salisbury veterans hospital knew it had problems well before federal
investigators showed up in 2005 to check on suspicious deaths.
In 2001, VA officials hired consultants to evaluate care at the
Charlotte area's main veterans hospital. Their findings, outlined in a
report obtained by the Observer, included sloppy patient records, poor
tracking of drugs and IV solutions mixed in unsanitary areas.
The hospital's infection rate had doubled in the previous year, the
consultants said, but the hospital did not take "concrete actions ... to
address this."
This is the third report the Observer has uncovered detailing poor
patient care by Salisbury hospital staff. The other two were the result
of VA inspections. Viewed together, the reports reveal an institution
repeatedly warned of practices that endangered patients' lives.
VA officials have told the Observer that they acted to fix problems
after each report.
And yet, in 2005, VA investigators found problems similar to those
consultants had documented four years earlier. They were investigating
an anonymous allegation of more than 12 suspicious deaths. Their 2005
report concluded the hospital had provided shoddy care in several cases,
including two in which men died.
Also at issue: The VA did not give any of the three reports to the Joint
Commission, a nonprofit group that sets nationally recognized
patient-care standards and inspects hospitals for compliance. The
commission is one of few outside monitors of patient care at VA
hospitals.
"It's certainly something we wish the VA would have shared with us,"
Elizabeth Zhani, a commission spokeswoman, said.
But disclosure isn't required, and the commission doesn't ask for such
reports, she said.
"That is amazing," U.S. Rep. Bob Filner, who chairs the House Veterans'
Affairs Committee, said Saturday. "A don't-ask-don't-tell policy is not
appropriate for the VA."
The California Democrat has scheduled congressional hearings starting
April 19 on the quality of VA health care. The hearings will focus on
the Salisbury hospital, which Filner calls a "case study" for
patient-care problems. Three N.C. members of Congress requested the
hearings following Observer stories.
"There's a tendency of any bureaucracy to cover up, ... but we're
talking about life and death here," Filner said.
Observer stories prompted the VA to send inspectors last week to the
Salisbury hospital. Results of last week's inspection "will provide us
important information about what additional corrective actions may be
needed to ensure veterans are receiving the best possible care," Matt
Burns, press secretary for the Veterans Affairs Department, said in an
e-mail. "One veteran not getting the care they deserve is one too many."
On Friday, VA officials did not answer questions about why problems
continued to occur.
"We're going to bring those people to the hearing," Filner said of
hospital and VA officials. "We'll get them on the record and under oath
and show you have to be accountable."
Low scores
In 2001, the VA wanted to see how the Salisbury hospital would fare in
an upcoming Joint Commission inspection.A satisfactory inspection is
supposed to mean a hospital is meeting high standards for patient care.
Seeking commission accreditation is voluntary but widely sought, in part
to assure patients they're in a high-quality facility. Accreditation
also often fulfills state licensing requirements.
The commission, which accredits about 15,000 health care groups
nationwide, is not a regulatory agency, but it can deny accreditation if
a facility doesn't fix problems. Inspections are done at least every
three years.
In advance of commission inspections, hospitals commonly hire outsiders
to determine whether they're in compliance. In 2001, the VA paid MagCare,
a private consulting firm, $225,230 for such inspections at Salisbury
and seven other hospitals.
MagCare consultants were at the Salisbury hospital for three days in
April 2001. They met with staff, reviewed records and inspected the
medical-surgical inpatient area, including the ICU and the emergency
room.
They rated how well the hospital met standards for care, leadership,
infection control and other key performance measures. Like the
commission, they used a five-level grading system.
The Salisbury hospital received the lowest score in 14 of 49 points
graded. Ten rated the second-lowest grade. That means that on nearly
half the measures, the hospital didn't perform well. The hospital had no
top scores, and only five points merited the second-highest grade.
All the problems "appear to be correctable" before the official
inspection, the report said. Consultants could not be reached.
The hospital fared better during its 2002 commission inspection,
although it was advised to correct some problems.
Infection rate doubled
Consultants noted that patients at the Salisbury hospital in 2001 were
contracting infections at double the previous year's rate.
Hospital-acquired infections are a leading cause of death nationwide,
making control procedures a priority. Yet consultants found that workers
mixed IV medications in areas that were not "even close to being"
sanitary. They saw dirty laundry stowed with clean linens, supplies
spilled on the floor, and "a startling amount of dust and dirt" behind
doors in the emergency department.
"You can pretty much go into any large hospital and find something you
don't like in terms of the cleanliness," said Howard Nussman, who does
similar hospital inspections. "But if my infection rate had doubled, and
I were the CEO of the hospital, I would be personally making rounds and
trying to resolve issues around cleanliness."
Nussman is an executive with Premier Inc., which has 600 employees in
Charlotte. The San Diego company's services include helping hospitals
track their quality of care. Nussman and Premier had no role in the 2001
inspection, but he reviewed the MagCare report at the Observer's
request.
A sample of other key MagCare findings:
• The hospital often didn't take patient medical histories within 24
hours.
That "would be an indicator that things are sort of slack," said Nussman,
adding he seldom sees that problem in a hospital. "It's hard to create a
treatment plan if the physician hasn't done a history and physical on
the patient."
• Anesthesia staff described "an unusual method of accounting for
narcotics" that consultants said created a high risk for theft or abuse
of drugs. Workers took as much as they thought they'd need for a
procedure but didn't record the amount. After a procedure, workers would
return leftover drugs and at that time record how much was used.
• The operating room wasn't available after hours, the report said. On a
Friday evening in June 2000, a patient with gastrointestinal bleeding
needed to see a surgeon. That didn't happen until Monday.
Most hospitals have rules that require such consultations within 24
hours, Nussman said. He added that he has been to small, rural hospitals
where "you don't see ... patients just sort of being on hold like that.
That's just really not acceptable."
Consultants said there was no evidence patients were seriously hurt, but
"the risk is significant."
"If the Salisbury campus cannot provide the same level of care during
off-duty hours, a better option might be to discontinue emergency care
and other medical-surgical inpatient care," the report said.
The hospital's operating room is now available around the clock, Adrien
Creecy-Starks, a VA spokeswoman, said Friday.
Other MagCare 2001 Findings
• Inadequate evaluation of doctors' work prior to renewing their
operating privileges at the hospital.
• Patients were not allowed personal clothing and wore identical pajamas
all the time, a practice that "infringes on personal dignity."
• Patient charts and surgical schedules were left out and were publicly
available.
• No process to ensure patients were evaluated to determine if they had
special nutrition needs.
• No process to ensure patients were screened for physical or
occupational therapy.
• No documentation that patients and family talked with staff about
rehabilitation goals.
Stella Hopkins: 704-358-5173
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Larry Scott --
