Dept. of Veterans Affairs releases report on Tuscaloosa VA Medical Center

VA Tuscaloosa Medical Center
VA Tuscaloosa Medical Center(VA Tuscaloosa Medical Center)
Published: Jul. 1, 2022 at 3:18 PM CDT|Updated: Jul. 5, 2022 at 3:10 PM CDT
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TUSCALOOSA, Ala. (WBRC) - Days after a group of nurses at the Tuscaloosa VA Medical Center protested over conditions at the hospital, WBRC FOX6 News is getting a look at a new report by the VA’s Office of Inspector General.

The 51-page report entitled “Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama” is the result of an anonymous complaint made last July.

Investigators substantiated two of the four complaints, including failure to fill key staff positions and failure to address security and safety issues that led to patients leaving property.

The introduction to the report reads: The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Tuscaloosa VA Medical Center (facility) in Alabama to assess allegations regarding the failure of facility leaders, including community living center (CLC) leaders, to address CLC security and safety issues known to them; this alleged failure resulted in a resident’s elopement.* The OIG also assessed allegations that facility leaders failed to fill key vacant positions, utilize unused space for the provision of patient care, and ensure the environment of care and maintenance of grounds provided a safe setting.

During the inspection, investigators also reported finding concerns related to the Patient Safety Program, but those will be assessed during a separate healthcare investigation.

Part of the report conclusion reads: The OIG substantiated that facility leaders failed to address CLC security and safety issues that resulted in resident elopements. The OIG found that facility leaders did not implement a 2018 HFMEA recommendation to install an electronic alarm system to prevent resident elopement until November 2021 (when a contract to purchase the system was awarded). During the inspection, the OIG identified concerns regarding the operability of security cameras in the CLCs, the security of the outdoor areas surrounding the CLC cottages, and use of elopement risk alerts in the EHR. The OIG determined these security and safety concerns likely contributed to or failed to mitigate resident elopements and further noted that timely follow-through on the resolution of these concerns, along with implementation of the recommended electronic alarm system, were imperative to the safety of CLC residents at the facility.

The report laid out ten recommendations and included responses from the Facility Director.

WBRC FOX6 News reached out to the Tuscaloosa VA about the findings of this report. April Jones, Public Affairs Officer, responded with a statement: “The VA OIG report focuses on events that occurred in July 2021. Since then, Tuscaloosa VAMC has started implementing each of the OIG’s recommendations. 6 of the 9 recommendations have been completed while the remaining 3 recommendations are being actively resolved and are anticipated to be complete within the next 2 months. The Veterans served by the Tuscaloosa VAMC deserve no less. While the details in this report do not represent the quality of healthcare Veterans in West Alabama have come to expect from our facilities, the report has prompted many improvements to prevent similar issues from happening in the future.”

The full report is below:

*The definition of elopement from health.maryland.gov is: a civilly admitted individual’s (whether voluntary or non-voluntary) unauthorized absence from the facility (building or grounds) when he or she is considered a danger to him/herself or others, regardless of length of time of absence.

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