Healthcare Inspection- Management of Patient Abuse Cases Charlie Norwood VA Medical Center, Augusta, Georgia

OIG conducted an inspection to determine the validity of allegations that two patient abuse cases were not managed properly, and as a result, patients were placed at risk at the Charlie Norwood VA Medical Center, Augusta, GA. We substantiated that some staff members and managers did not comply with policies for reporting patient abuse, evaluating victims of the alleged abuse, or evaluating the events. We also substantiated that some managers did not take appropriate or timely administrative action relative to the events. While non-compliance with policy may potentially place patients at risk, we found no evidence that patients were actually harmed by these procedural breaches. We substantiated that a senior executive acted improperly in relation to the administrative action in the case of substantiated patient abuse and that responsible managers did not report a nurse to the State Licensing Board as required. We recommended that the Medical Center Director ensure that: appropriate staff are trained regarding reporting and evaluation of alleged patient abuse cases and the AIB process; and AIBs are completed timely, actions are implemented and tracked to completion, and SLB reporting is completed when indicated. The VISN and Medical Center Directors concurred with our recommendations and provided acceptable action plans.