VA Nursing Homes in 25 States Cited for Serious
“Immediate Jeopardy”
Deficiencies in 2018
Recently released reports from private contractor inspectors revealed from April through December 2018, citations were issued for deficiencies causing “actual harm” in 52 of the 99 Veterans Affairs (VA) nursing homes inspected. The facilities cited for harmful deficiencies were located in 25 states, the District of Columbia, and Puerto Rico.
The report revealed that the health and safety of many veterans was jeopardized. For example, in three facilities veterans were in “immediate jeopardy” and in eight other facilities veterans’ health and safety were both jeopardized and actually harmful.
Inspectors found that in over two dozen of the VA nursing homes, staff were not following protocols to ensure that pressure sores did not develop or to promote healing when they did occur. One specific incident in the report involved a veteran who over a period of six months developed five pressure sores. The inspectors noted that during their visit the resident was never repositioned nor did staff place cushions to alleviate pressure for several hours.
VA Officials issued a statement in response to the report asserting that the care residents in VA nursing homes need is more complex and more difficult to provide than residents in private facilities. In support of this statement, they reported that 42 percent of the residents in VA facilities last year were at least 50 percent disabled due to their military service.
According to VA Secretary Robert Wilkie, “VA’s nursing home system compares closely with private sector nursing homes.”
A VA spokesman pointed out that non-VA nursing homes also have problems, and with this first-time posting of the VA reports, “we hope to drive improvements throughout the system.”
Compliance Perspective
Failure by a nursing home to ensure the health and safety of its residents and to provide the level of care needed may result in residents being placed in “immediate jeopardy” and/or actually harmed, which may be considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the level of care needed by the residents and the level of staff needed to provide that care.
- Train staff regarding abuse and neglect and following protocols for preventing and caring for residents with pressure sores.
- Periodically audit to ensure that the staffing levels are maintained to provide the level of care needed for the residents the facility has admitted for care. Audit to ensure that repositioning of residents and placement of pressure relieving/reducing devices occurs in accordance with residents’ care plans.
