Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Management of Patient Abuse Cases
 

Charlie Norwood VA Medical Center
 

Augusta, Georgia
 

Report No. 11-01997-289 September 21, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 

 


 


 


 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
 
 

	 

	 

	 

	 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Executive Summary
 

The Office of Inspector General Office of Healthcare Inspections conducted an 

inspection related to the management of patient abuse incidents at the Charlie Norwood 

VA Medical Center, Augusta, GA. The complainant alleged that patient abuse cases 

were not managed properly, and as a result, patients were placed at risk. 

We substantiated that some staff members and managers did not comply with policies for 

reporting patient abuse, evaluating victims of the alleged abuse, or evaluating the events. 

We also substantiated that some managers did not take appropriate or timely 

administrative action relative to the events. While non-compliance with policy may 

potentially place patients at risk, we found no evidence that patients were actually harmed 

by these procedural breaches. 

We substantiated that a senior executive acted improperly in relation to the administrative 

action in the case of substantiated patient abuse and that responsible managers did not 

report the nurse to the State Licensing Board as required. 

We made four recommendations. We recommended that the Medical Center Director 

ensure that: 

	 Staff members and managers receive training regarding the appropriate reporting 

and evaluation of alleged patient abuse cases. 

	 Staff responsible for the Administrative Investigation Board process receive 

appropriate training. 

	 Administrative Investigation Boards are completed in a timely manner, and that 

actions are implemented and tracked to completion. 

	 The appropriate process is followed when State Licensing Board reporting is 

indicated. 

The Veterans Integrated Service Network and Medical Center Directors concurred with 

the findings and recommendations and provided an acceptable action plan. We will 

follow up on the planned actions until they are completed. 

VA Office of Inspector General i 
 
 

 
 

 
 

	 

	 

	 

	 

DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, VA Southeast Network (10N7) 

SUBJECT:	 Healthcare Inspection – Management of Patient Abuse Cases, Charlie 

Norwood VA Medical Center, Augusta, Georgia 

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted 

an evaluation in response to a confidential complainant regarding alleged 

mismanagement of two patient abuse incidents. The purpose of our review was to 

determine whether the allegations had merit. 

Background

The Charlie Norwood VA Medical Center is a two-division facility located in Augusta, 

GA. The facility provides medicine, surgery, mental health, rehabilitation, and spinal 

cord injury services. It has 278 hospital beds, 60 domiciliary beds, and 132 community 

living center beds. The facility is part of Veterans Integrated Service Network (VISN) 7 

and serves approximately 101,000 veterans throughout east central Georgia and west 

central South Carolina. 

On February 18, 2011, a confidential complainant alleged that two patient abuse 

incidents, which occurred in 2010 under previous facility leadership,1 were not managed 

properly, and as a result, patients were placed at risk. Specifically, the complainant 

reported that: 

	 Some facility staff members did not comply with local policy regarding the 

reporting of alleged patient abuse. 

	 Some facility managers did not comply with local policies regarding completion 

of administrative actions. 

Local policy describes patient abuse as any acts against patients that involve physical, 

psychological, sexual, or verbal abuse. Employees are required to report cases of actual 

1 The previous facility leadership included the Medical Center Director, Associate Director for Patient Care 

Services, and the Quality Manager. 

VA Office of Inspector General 1 
 

 

 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

and suspected abuse, and managers are required to assure a timely and appropriate 

investigation of the facts and circumstances. Veterans Health Administration (VHA) 

Human Resource (HR) regulations provide a table of penalties for the administration of 

disciplinary actions in cases of substantiated patient abuse.2 

The complainant also cited personnel-related issues, which were outside of the OIG’s 

purview, and were not addressed in this report. 

Scope and Methodology

We conducted a site visit April 19–20, 2011. We interviewed the acting Risk Manager, 

acting Quality Management (QM) Coordinator, QM staff, ANEs, Associate Director for 

Patient Care Services, patient safety office staff, patient advocates, and the Chief and 

Assistant Chief of HR. We reviewed VHA and local policies and facility documents 

related to the reports and investigations of incidents of alleged patient abuse occurring 

between July 16, 2009, and April 20, 2011. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results

Issue 1. Compliance with Patient Abuse-Related Policies

We substantiated that some staff members and managers did not comply with policies for 

reporting patient abuse, evaluating victims of the alleged abuse, or evaluating the events. 

We also substantiated that some managers did not take appropriate or timely 

administrative action relative to the events. While non-compliance with policy may 

potentially place patients at risk, we found no evidence that patients were actually harmed 

by these procedural breaches. 

The Table (on the following page) shows several important action steps for reporting, 

evaluating, and managing cases of actual and suspected abuse as outlined in local and 

VHA policies. Elements denoted with an asterisk indicate that while the steps were 

completed, they were not completed in a timely manner. 

2 VA Handbook 5021, Employee/Management Relations, April 15, 2002. 

VA Office of Inspector General 2 
	 

	 

	 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Table. Policy Requirements for Reporting, Evaluating, and Managing Abuse Cases 

Policy Requirement Case 

1 

Case 

2 

Witnessing employee notifies immediate supervisor without delay Yes Yes 

Supervisor notifies Medical Officer of the Day (MOD) without delay No No 

Supervisory nurse and MOD examine patient immediately No No 

Supervisor notifies Police and Security Service (P&SS) without delay; 

P&SS conducts a preliminary investigation 

No Yes 

Witnessing employee completes an incident report of the event within 

24 hours 

No No 

The responsible ANE completes a fact-finding review 

(suggested completion within 7 days) 

Yes* Yes 

The Service Line Executive relieves the alleged abusing employee of 

patient care duties pending completion of the fact-finding or administrative 

investigation board (AIB) 

Yes* Yes 

Case 1. The elapsed days from the date of the event to initiation of the final 

administrative actions totaled 242 days. The facility-level fact-finding review, which 

took about 4 months to complete, did not substantiate patient abuse in Case 1. However, 

some staff members (witnessing employee, charge nurse, nurse manager, and ANE) had 

not followed procedures to report and evaluate the suspected abuse event as required by 

policy. We found that: 

	 The MOD was not notified immediately of the suspected abuse, and the nurse 

supervisor and MOD did not conduct a physical examination of the patient. When 

these examinations are not promptly completed, physical evidence may be lost. 

	 P&SS was not notified of the suspected abuse, and therefore, did not complete an 

investigation that may have been needed for legal purposes. 

	 The alleged abusing employee (referred to as Nurse A) was not removed from 

direct patient care for more than 2 weeks after the event. In this case, Nurse A 

was not found to have abused the patient. However, immediate removal of subject 

employees from patient care activities pending the completion of relevant factfinding is an important step to ensure patient safety. 

Due to delays in completing the fact-finding review and providing related conclusions 

and recommendations, Nurse A was not returned to clinical duties on the unit until 

6 months after the incident occurred, and administrative actions related to procedural 

lapses did not occur until 7 months after the event. These delays potentially 

compromised the reliability of witness’ accounts of the events and due process for the 

involved employees. Because Nurse A was assigned to non-clinical duties for 

VA Office of Inspector General 3 
	 

	 

 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

approximately 6 months, the delays also affected Nurse A’s availability for direct patient 

care. 

Case 2. The elapsed days from the date of the event to final closure totaled 280 days. 

The AIB substantiated patient abuse in Case 2. We found that: 

	 The AIB was not completed in the 45-day time frame, the administrative action 

was not initiated for more than 60 days after the AIB was completed, and the case 

was not closed until nearly 6 months after completion of the AIB. The abusing 

employee (Nurse B) was placed in an off-duty with pay status for more than 

3 months after the AIB substantiated abuse. The delay may have caused an 

unnecessary expenditure of resources. 

	 Without making comments or recommendations, the acting facility Director closed 

the AIB about 4 months after abuse was substantiated. By policy, the acting 

Director should have certified completion within 30 days. Further, the acting 

Director’s failure to make recommendations in a substantiated case of patient 

abuse reflects either a lack of understanding or a lack of involvement in the 

proceedings. 

To determine whether the deficiencies found in the above cases were unique or part of a 

systemic problem, we expanded the scope of our inspection to evaluate the timeliness of 

incident reports, fact-findings, and AIBs for 10 other alleged patient abuse cases, which 

occurred in fiscal years (FYs) 2010 and 2011 through March 30, 2011. Four cases did 

not have an incident report completed, and only one of the remaining six cases had an 

incident report completed within the required 24-hour timeframe. Seven cases had factfinding reviews only, and five of those reviews were not completed within the suggested 

7-day timeframe. Only one of the three AIBs was completed within the 45-day 

timeframe. 

The two cases of alleged patient abuse occurred in 2010, and since that time, many of the 

facility leaders have changed. The individual previously responsible for oversight of the 

AIB process retired. At the time of our visit, we found that only one individual had 

formal training on the AIB process, which limited the facility’s ability to ensure the 

timely completion of thorough and credible AIBs. 

The facility’s new leadership changed the process for reporting alleged patient abuse. All 

incidents are now reported to the Chief of Staff, the Administrative Assistant to the Chief 

of Staff, and the respective nurse manager and ANE. 

Issue 2. Completion of Administrative Actions

We substantiated that a Senior Executive acted improperly in relation to the 

administrative action against Nurse B and that responsible managers did not report Nurse 

B to the State Licensing Board (SLB) as required. 

VA Office of Inspector General 4 

 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Improper Actions. A senior executive did not follow through on a proposed termination 

issued to Nurse B in mid-October; rather, the executive delayed the termination. Thus, 

Nurse B was able to pursue a position at another VA healthcare facility without having to 

disclose the substantiated patient abuse or proposed termination. This was done without 

consulting HR or the facility Director. 

In an e-mail to the HR chief in early December, the senior executive wrote that Nurse B 

“is working to transfer to [unnamed] VA to be closer to nurse B’s father. I am okay with 

the transfer in lieu of termination” for humanitarian reasons. The e-mail went on to say 

that, the [unnamed] VA facility had not asked for a reference; therefore, it would 

“become their problem.” 

At the senior executive’s request, HR prepared a letter reflecting that the proposed 

removal was being “administratively withdrawn” while Nurse B “pursues transfer.” 

Nurse B received the letter 3 days later. 

Nurse B was not selected for transfer to the other VA, and in mid-January 2011, HR 

informed nurse B that the proposed removal would be reinstated and that nurse B was to 

return to work in late January.3 

In mid February, a senior executive e-mail granted Nurse B another 3 weeks to “have a 

commitment for employment from another VA or your termination will be effective on 

March 2, 2011.” Nurse B resigned from Federal service in late February without 

resuming any direct patient care duties. 

The senior executive should have promptly implemented and followed through on the 

proposal to remove because the executive had a responsibility to protect patients from the 

potential threat of an abusive employee. Because the executive signed the original 

removal letter in October and then reinstated it after learning that Nurse B did not get the 

transfer, it seems to reflect the executive’s agreement that removal was an appropriate 

penalty in this case. While Nurse B would have been free to pursue transfer to another 

VA facility at any time during the process, the actions indicated that the senior executive 

did not understand or fully acknowledge the gravity of the situation and the potential 

threat of harm to future patients. 

Reporting to the SLB. Responsible managers did not follow the necessary steps to report 

Nurse B to the SLB. VHA is responsible for ensuring that its patients receive appropriate 

and safe health care and requires4 that its facilities report each licensed health care 

professional whose behavior or clinical practice so substantially failed to meet generally 

accepted standards of clinical practice as to raise reasonable concern for the safety of 

patients. Patient abuse is specifically listed as an example of a reportable event. 

3 Reinstatement of the proposed termination “reset the clock” of due process. Nurse B was assigned to a nonclinical position in another division during this time.

4 VHA Handbook 1100.18, Reporting and Responding to State Licensing Boards, December 22, 2005.
 

VA Office of Inspector General 5 
Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

The facility should have reported the patient abuse findings relative to Nurse B to VACO 

officials who would then make the official report to the SLB, if indicated. The SLB then 

determines whether modification, suspension, or revocation of a professional’s license to 

practice is warranted. Because facility managers did not report to VACO, no report was 

made to the SLB. Without appropriate reporting, health care providers with substantiated 

performance and/or conduct issues could transfer to other VA or private-sector facilities 

and potentially place patients at risk for harm. 

Conclusions

We substantiated that some staff members and managers did not comply with policies for 

reporting patient abuse, evaluating victims of the alleged abuse, or evaluating the events. 

We also substantiated that some managers did not take appropriate or timely 

administrative action relative to the events. While non-compliance with policy may 

potentially place patients at risk, we found no evidence that patients were actually harmed 

by these procedural breaches. We substantiated that a senior executive acted improperly 

in relation to the administrative action in the case of substantiated patient abuse and that 

responsible managers did not report Nurse B to the SLB as required. 

Recommendations

Recommendation 1. We recommended that the Medical Center Director ensure that 

staff members and managers receive training regarding the appropriate reporting and 

evaluation of alleged patient abuse cases. 

Recommendation 2. We recommended that the Medical Center Director ensure that 

staff responsible for the AIB process receive appropriate training. 

Recommendation 3: We recommended that the Medical Center Director ensure that 

AIBs are completed in a timely manner and that actions are implemented and tracked to 

completion. 

Recommendation 4: We recommended that the Medical Director ensure that the 

appropriate process is followed when SLB reporting is indicated. 

VA Office of Inspector General 6 

 


 


 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Comments

The VISN and Medical Center Directors agreed with the findings and recommendations 

(see Appendixes A and B, pages 8–11, for the full text of their comments). The 

implementation plans area acceptable, and we will follow up on the planned actions until 

they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 7 
 

 

 

 


 


 


 


 


 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: August 15, 2011
 

From: Acting Director, VA Southeast Network (10N7)
 

Subject: Healthcare Inspection – Management of Patient Abuse Cases,
 

Charlie Norwood VA Medical Center, Augusta, Georgia 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Thru: Director, Management Review Service (10A4A4) 

1. The VA Southeast Network’s Quality Management Officer 

has reviewed the proposed actions and status updates in this 

enclosed plan and concur with the actions as described. 

2. If there are any questions please contact Robin Hindsman, 

Psy.D, Quality Management Officer. 

(original signed by:)

James A. Clark
 

Acting Director, VA Southeast Network (10N7)
 

VA Office of Inspector General 8 
 

 

 

 

	 

	 

	 

	 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Appendix B

Medical Center Director Comments

Department of

Veterans Affairs Memorandum

Date:	 August 10, 2011 

From:	 Acting Director, Charlie Norwood VA Medical Center 

(509/00) 

Subject:	 Healthcare Inspection – Management of Patient Abuse Cases, 

Charlie Norwood VA Medical Center, Augusta, Georgia 

To:	 Acting Director, VA Southeast Network (10N7) 

Concur with all recommendations. Actions have been taken 

and are in progress as noted in the comments section. 

(original signed by:)

Richard T. Rose 

Acting Director, Charlie Norwood VA Medical Center 

(509/00) 

VA Office of Inspector General 9 

 

 
 


 


 


 


 


 


 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations
 

Recommendation 1. We recommended that the Medical Center Director
 

ensure that staff members and managers receive training regarding the
 

appropriate reporting and evaluation of alleged patient abuse cases.
 

Concur Target Completion Date: October 7, 2011
 

Facility’s Response:
 

By October 7, 2011, just in time training will be coordinated by Education 

and Nursing, as well as a full campaign to ensure that staff and managers 

understand reporting avenues and time frames. 

Status: In process 

Recommendation 2. We recommended that the Medical Center Director 

ensure that staff responsible for the AIB process receive appropriate 

training. 

Concur Target Completion Date: October 7, 2011 

Facility’s Response: 

Formal training for all members of the AIB process will occur by the target 

date led by Quality Management and Human Resource staff. Just in time 

and reinforcement training for all staff who serve on an AIB began in 

March 2011. 

Status: In process 

Recommendation 3. We recommended that the Medical Center Director 

ensure that AIBs are completed in a timely manner and that actions are 

implemented and tracked to completion. 

Concur Target Completion Date: October 7, 2011 

VA Office of Inspector General 10 
Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Facility’s Response: 

A process for timeliness and tracking was put in place on March 2, 2011 to 

reinforce requirements and ensure closure on conclusions forwarded by the 

Board. Every Administrative Investigative Board that is chartered is 

educated on expectations and requirements and Quality Management tracks 

accomplishments. There have been four AIBs, three have been completed 

and two out of three were completed on time, one with an approved 

extension. One is currently pending an extension. 

Status: In process 

Recommendation 4. We recommended that the Medical Center Director 

ensure that the appropriate process is followed when SLB reporting is 

indicated. 

Concur Target Completion Date: October 7, 2011 

Facility’s Response: 

The Handbook clearly lays out the steps to be followed in any reporting to 

the State Licensing Board. The Chief of Human Resources and the acting 

Risk Manager in Quality Management have been assigned action to oversee 

the process. Quality Management and Human Resources will work 

together to ensure compliance with reporting to the State Licensing Board 

in accordance with VA regulations. 

Status: In process 

VA Office of Inspector General 11 
 

 

	 

	 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Toni Woodard, Team Leader 

Thomas Jamieson, MD 

Michael Shepherd, MD 

Susan Zarter, RN 

VA Office of Inspector General 12 
 


 

Management of Patient Abuse Cases, Charlie Norwood VA Medical Center, Augusta, GA 

Appendix D

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southeast Network (10N7) 

Director, Charlie Norwood VA Medical Center (509/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Saxby Chambliss, Jim DeMint, Lindsey Graham, Johnny Isakson 

U.S. House of Representatives: John Barrow, Paul C. Broun, Jeff Duncan, Joe Wilson 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 13