A new report released Tuesday details more than two dozens problems found during a recent inspection of the Salisbury VA Medical Center.
The inspection was conducted by the Department of Veterans Affairs Office of Inspector General during a week in March. Inspectors found more than two dozen problems during their review, which spanned from March of this year all the way back to Fiscal Year 2015.
An executive summary of the report provided a summary of what inspectors found. As a result of the findings, we could not gain reasonable assurance that the facility:
- Has effective documentation, communication, and quality improvement processes for decisions involving utilization management
- Maintains a clean environment of care in the Emergency Department and has a policy and procedure for the reprocessing of reusable medical equipment
- Maintains a safe environment of care with consistent dire drills, labels food items in the nourishment refrigerators, and secures chemicals in the hemodialysis unit
- Provides effective anticoagulation therapy management patient education
- Has a safe inter-facility transfer process
- Performs quality control testing on glucometers
- Provides safe moderate sedation care
- Provides effective community nursing home oversight
- Has an effective process for the management of disruptive/violent behavior incidents
- Maintains a safe Mental Health Residential Rehabilitation Treatment Program environment
The inspection was conducted as part of the Clinical Assessment Program, a cycle of regular inspections conducted at VA medical centers across the country every three years.
Among the detailed findings, the inspectors found the medical center lacked proper written procedures to ensure reusable medical equipment was being properly cleaned between uses on different patients. Inspectors also found a number of processes not being completed when patients were being transferred within departments at the medical center; including doctors failing to sign off on transfers, the reason patients were being transferred and basic information about the patient’s previous care from doctors and nurses.
Inspectors found that doctors at the Salisbury VA Medical Center were not properly warning other doctors and care providers of possible adverse effects of powerful medication when transferring patients.
In May, a WBTV investigation uncovered the case of one veteran who died at the Salisbury VA last September after being prescribed a high doses of powerful narcotics.
The report also details deficiencies inspectors found in the hospital’s handling of patients with violent and disruptive behavior and failure on the part of staff at the mental health rehabilitation in-patient facility did not make regular checks of patients’ beds and rooms as required.
The medical center’s director, Kaye Green, announced her resignation from the VA unexpectedly in April. Green’s role is being filled on an interim basis by Dr. Subbarao Pemmaraju, who had previously been the hospital’s chief of staff under Green, and Lynette Baker, who served as associate director under Green.
In an interview Wednesday, Baker said the report’s findings did not cause her worry or concern. Pemmaraju characterized the problems outlined in the report as technical and not substantive issues that put veterans’ lives in danger.
“There was nothing related to morbidity, mortality or any quality care concerns that they mentioned,” Pemmaraju said.
Although the report largely focused on the dozens of new deficiencies at the Salisbury VA, the report did include new wait-time statistics that showed most new and returning patients waited two weeks or less for care.
The report notes that the data was not verified by the OIG inspectors.
Last October, the inspector general released a report that found supervisors at the Salisbury VA Medical Center manipulated wait time data in order to increase their performance evaluations and, in turn, receive higher bonus payouts.
The report includes a letter from Pemmaraju in which he concurs with the OIG’s findings and offers explanations for some deficiencies and a plan to improve all 26 areas cited in the report.
“Do we still have areas that we need to improve on? Absolutely,” Pemmaraju said. “Like any other health system, we have areas where we need to work on, absolutely, including the OIG report, which we take very seriously. We want to make absolutely sure we fix everything.”
North Carolina’s two United States senators, Richard Burr and Thom Tillis, issued a joint statement reacting to the new report.
“This report serves as an important reminder of the necessary work that remains to be done to improve VA facilities in North Carolina and across the country,” the senators said. “We’re grateful to the Office of Inspector General for catching these issues so they can be directly addressed and resolved.”
This is the third report from the OIG outlining problems at the Salisbury VA to be released since October. Despite the string of reports documenting problems at the embattled medical center, Baker said veterans should still feel confident they will receive quality care from doctors and staff at the medical center.
Baker noted that, as an Air Force veteran herself, she chooses to receive care at the Salisbury VA.
“I’m proud to go there, I’m very happy with my care,” Baker said. “I’d go there if I didn’t work there.”