Healthcare Inspection - Quality of Care, Communication, and Infection Control Issues, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina

OIG evaluated allegations of inadequate patient care, poor communications with family, poor coordination of care, and inappropriate infection control practices. While we confirmed that some of the alleged conditions existed during a veteran’s hospitalization, in many cases, facility leaders had already taken actions to improve care and service delivery. We did not substantiate other allegations related to quality of care and environmental deficiencies. We recommended that patients assessed to be at nutritional risk are promptly evaluated by appropriate dietary staff, that nursing personnel are trained on the steps required to initiate consult requests through the electronic nursing assessment package, and that actions are taken to evaluate and revise the Do Not Attempt Resuscitation template note, as appropriate, to be more patient-specific and patient-centered. The VISN and facility Directors concurred with our findings and recommendations and provided acceptable improvement plans.