Deficient Care at a Los Angeles VA-Approved Facility Resulted in Medication Errors, One Veteran Reported Alive Days after His Death
August 09, 2019
OSC has alerted the President and Congress to deficient patient care at a Los Angeles VA-approved community care facility where staff were unable to correctly identify a veteran who died days earlier.
The U.S Office of Special Counsel (OSC) today alerted the President and Congress to deficient patient care at a Los Angeles VA-approved community care facility where staff were unable to correctly identify a veteran who died days earlier.
VA investigators observed the California Villa facility in disrepair and a disorganized medicine room, and the VA's report confirmed longstanding and well-known care issues at the facility. In one instance, staff were unable to correctly identify a veteran who died on October 8, 2017. The veteran's case manager entered a note on October 12, 2017, that she had a live encounter with the veteran that day, four days after he died. The case manager indicated that staff at the facility had directed her to a patient they confirmed was the veteran, but who turned out to be the wrong individual.
The VA's report also found that between 2015 and 2018, several veteran residents at California Villa experienced serious errors related to their medications, including: failure to provide physician-prescribed antibiotics to a 100-year old veteran with sepsis, and failure to update physician-canceled prescriptions resulting in a veteran receiving double doses of medication.
The VA's report recommended that the community care program coordinator conduct monthly visits to all VA-approved facilities, and that the position be made full-time. The agency also recommended an independent review of all VA-approved community care facilities, including inspection reports. These recommendations were all completed as of June 2019.
“When the VA partners with community care facilities, our veterans should be confident that their medical care will be top-notch," said Special Counsel Henry J. Kerner. “If staff at these facilities are unable to properly identify residents, veterans will not be receiving their proper medications. Because whistleblowers spoke up, the VA has taken strong steps to ensure these community care facilities are closely monitored to provide appropriate care."