Fed inspectors issue report on unannounced visit to Louis A. Johnson VA Medical Center

— Better documenting of medical staff privileging.

— Making sure patient care areas are safe and clean.

One of the safety issues involved inspector general officials finding unlocked Emergency Department supply carts in patient rooms, “which provided an opportunity for patients and visitors to access medical supplies, including needles.”

Also, inspectors “found dust in rooms used to store clean supplies and equipment,” as well as electrical cords “stretched taut,” which presented a tripping hazard.

— Regularly testing panic alarms in the mental health unit while documenting VA Police response times.

— Making sure that mental health inpatient unit rooms and the Emergency Department are set up so that patients with self-destructive behavior can be kept safe.

Inspectors learned of a report that patients with mental health concerns had been placed in a room that hadn’t been adequately checked, according to the report.

— Making sure that when patients are found to be a suicide risk, staff conduct a risk evaluation within the same calendar day whenever possible.

Inspectors “determined staff did not complete the evaluation for 45 percent of patients who had a positive screen, based on electronic health records reviews. Of the completed evaluations [inspectors] found, staff did not complete 25 percent of them on the same calendar day or within 24 hours of the positive screen in situations appropriate for same-day evaluation.”

Officials with the VA Medical Center answered all the responses by investigating to see if further problems existed and developing improvement plans in each area.

The report documented the massive scope of the Medical Center, which saw its budget increase from $243 million in fiscal 2020 to $308 million in fiscal 2022.

The Medical Center had about 21,300 unique patients in fiscal 2020 and about 290,100 outpatient visits; those numbers went up to 21,956 unique patients in fiscal 2022 and about 294,600 outpatient visits.

The employees at the facility dropped from 887 in fiscal 2020 to 845 in fiscal 2022.

The murders that occurred in 2017 and 2018 also were mentioned in the report, with Medical Center Executive Director Barbara Forsha, who has been leading the facility since January 2021, saying “there was a need to build trust with staff” following the murders.

Executives started making regular visits to staff in patient care locations, including on evenings and weekends, Forsha told inspectors.

Forsha also cited the 2021 trial of the serial killer nursing assistant as taking “an emotional toll on staff,” which “led to high nursing turnover,” according to the report.

Due to the nursing turnover, Medical Center officials said they closed the medical/surgical inpatient unit, combining its services with the intensive care unit, until they could hire new staff.

The facility added providers who only worked in the hospital in 2022 as a way to improve patient satisfaction, according to the report. Plans were also in place to increase the number of clinics, as well as turning to expanded telehealth appointments for everything from dermatology and hospice to oncology and cardiology.

The Medical Center reported the following average patient counts per day in fiscal 2022: 11 in the community living center; eight domiciliary; 12 medicine; two mental health; zero surgery.