Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Alleged Patient Neglect and Abuse
 

VA Central California Health Care
 

System
 

Fresno, California
 

Report No. 11-01184-293 September 28, 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)
 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an

inspection to determine the validity of an allegation regarding patient neglect and abuse

at the VA Central California Health Care System (the system), Fresno, CA. A

complainant alleged that a patient developed bed sores (pressure ulcers) due to neglect

and abuse while an inpatient on the system’s medical units and as a resident in the

system’s community living center.

We found that the patient did develop pressure ulcers while being treated by the system

as well as subsequent pressure ulcers that developed when not an inpatient. However, we

concluded that these were not the result of neglect or abuse. More likely, they resulted

from his debilitated, catabolic state, and the insertion of a Foley catheter used in the

treatment of life-threatening urosepsis. The patient’s skin breakdown was identified and

attended to in a timely manner. This report makes no recommendations.

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Director, VA Sierra Pacific Network (10N21)

SUBJECT: Healthcare Inspection – Patient Neglect and Abuse, VA Central

California Health Care System, Fresno, California

Purpose 

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

an inspection to determine the validity of an allegation regarding patient neglect and

abuse at the VA Central California Health Care System (the system) in Fresno, CA. The

complainant alleged that the patient developed bedsores1 (pressure ulcers) while an

inpatient on the system’s medical units, and as a resident in the system’s community

living center (CLC). The purpose of the review was to determine whether the allegation

had merit.

Background 

The system is a 56 bed acute care, general medical and surgical center with primary,

secondary, and tertiary care in major diagnostic and treatment specializations. Five

primary care teams and numerous specialty care clinics, including mental health and

women’s health, provide extensive outpatient services in a managed care environment. A

60 bed CLC provides skilled nursing and rehabilitation care. The system serves a veteran

population of approximately 103,000 throughout six counties in central California and is

part of Veterans Integrated Service Network (VISN) 21.

On January 10, 2011, a complainant contacted the OIG hotline with an allegation that a

patient developed bedsores due to neglect and physical elder abuse while both an

inpatient of the system and a CLC resident.

1 Bedsores are painful skin ulcers that form when constant pressure on parts of the body shut down blood vessels

supplying that area of the skin.

1 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

Scope and Methodology 

We conducted a site visit on March 21–23, 2011. During our visit, we interviewed the

Chief of Medical Service, physicians, nurse managers, nurses, social workers, dietitians,

wound care specialists, the palliative care coordinator, and the discharge planner. We

reviewed VHA and local policies and procedures, the patient’s medical record, Activity

of Daily Living flow sheets from the medical units and CLC, quality management

documents, and published journals.

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.

Case Summary 

The patient was a man in his seventies with a medical history of chronic kidney disease,

diabetes mellitus, hypertension, and noncompliance with his medication regimen. In

mid-October, 2010, the patient was seen in the system’s Renal Clinic for a routine

follow-up appointment and was sent to the Emergency Department (ED) due to severely

elevated blood pressure. While in the ED, he became confused and disoriented with

slurred speech, drooling, and left-sided weakness. The patient had an emergent

endotracheal intubation2 due to a respiratory arrest.

The patient was admitted to the Special Care Unit (intensive care and telemetry unit) with

a diagnosis of a hypertensive emergency episode and possible stroke. As part of the

nursing assessment of the patient, no skin breakdown was identified. The patient’s initial

skin assessment using the Braden Scale3 was 13 (moderate risk). The system’s pressure

ulcer protocol was initiated, which included the following:

 Turn and reposition patient every two hours while in bed.

 Use pillows to separate pressure points.

 Place cushion while in a wheelchair.

 Elevate the heels using pillows or foam blocks.

 Apply heel/elbow pads.

 Avoid turning/positioning patient on side at greater than a 30-degree angle.

2 Endotracheal intubation is a medical procedure in which a flexible plastic tube is placed into the windpipe to
 

maintain an open airway.

3 The Braden Scale is a tool used for predicting the risk of developing pressure ulcers; this assessment is performed
 

by a staff nurse. The scale runs from 6-23, with lower numbers indicating higher risk.
 

VA Office of Inspector General 2 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

The patient’s nutritional risk assessment revealed a moderately compromised albumin

(serum protein) level of 2.9 (normal range 3.4–5.4) grams per deciliter.4

The next day, the patient’s endotracheal tube was removed. The nurses noted periods of

confusion and urinary incontinence (loss of bladder control). A physician wrote that the

patient attempted to get out of bed without assistance and was at risk for injury,

warranting the use of restraints.

The patient was transferred to the medical/surgical unit on hospital day (HD) 7. At that

time, his skin assessment score was 17 (mild risk). The nurse noted no pressure ulcers or

other skin problems. The physical therapist saw the patient for muscle strengthening and

noted increased confusion, lethargy, and decline in function.

On HD 8 a bladder scan5 was done, which revealed greater than 600 milliliters of retained

urine in the bladder. A Foley catheter was inserted to ensure adequate drainage of the

bladder. A physician noted the continued use of restraints as the patient attempted to

remove medical devices/tubes and lacked decision-making capacity.

On HD 9 the patient was admitted to the CLC for rehabilitation care. The nurse noted no

pressure ulcers and a skin assessment score was again 17. The patient’s Foley catheter

was in place. The nurse wrote that the patient would need much assistance with his

activity of daily living and transfers. The restraint order was not renewed.

On HD 13, a physical therapist noted that the patient demonstrated increased difficulty

with walking. The patient was seen in physical therapy the following day. Because of

further decline in his mental and functional status, he was unable to participate in

rehabilitation. The physical therapist wrote that the patient was not able to follow simple

directions and appeared to have been hallucinating.

On HD 18, the nurse noted an open area at the tip of the patient’s penis. The area was

cleansed with normal saline and aloe vesta cream6 was applied. On November 13, a

nurse documented two abrasions/lacerations on the scrotum and erosion at the tip of the

penis, “most likely from the Foley catheter.” The nurse wrote that both areas were

cleansed with normal saline and XeroformTM (a sterile gauze wound dressing) applied

twice a day. The patient had been refusing care (shower, medications, meals, and getting

out of bed).

On HD 26, the nurse found the patient unresponsive with an elevated temperature of

102.6°Fahrenheit and transferred him to the ED for further evaluation. The ED

physician documented, “penis with Foley and bloody” and diagnosed him with a urinary

4 A low albumin level is an indication of malnutrition.
 5 A bladder scan is a noninvasive method of assessing the volume of urine in the bladder.
 6 Aloe vesta cream is used as a barrier to help protect sensitive skin from pressure ulcers and other skin injuries.
 

VA Office of Inspector General 3 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

tract infection and septic shock.7 The ED nurse noted a skin assessment score of 11 (high

risk) and implemented the system’s pressure ulcer protocol. The patient was transferred

to the Special Care Unit.

On HD 27, the Wound/Ostomy Nurse documented necrotic (dead) tissue on the edges of

the penis consistent with a pressure ulcer. A stage II pressure ulcer8 was noted on the

coccyx (tailbone) measuring 1.5 x 1.5 centimeters (cm) and was treated with aloe vesta

cream. The nursing staff placed the patient on an air mattress overlay9 to minimize the

risk of further skin breakdown.

On HD 28, the patient had a nasogastric tube (NGT) inserted for administration of tube

feedings. However, the following day the patient pulled out the NGT and was started on

a pureed liquid diet. A dietitian assessed the patient and wrote, “albumin declining (2.1

grams per deciliter), which suggest severe visceral protein [amount of protein in the

internal organs] depletion.” A physician documented that the Foley catheter was

removed to promote healing of the penile ulcer. The nurse placed the patient in adult

diapers due to incontinence. Nurses later applied a condom catheter10 to keep his skin

dry.

On HD 30, the patient was transferred to the medical/surgical unit. The Wound/Ostomy

Nurse noted a stage II pressure ulcer located on the coccyx area and a fissure (cut or tear)

on the buttocks measuring 4 x 5 cm. The nursing skin assessment score was 11 (high

risk).

The physical therapist noted that the patient demonstrated a steady decline in functional

mobility. The patient was not able to lift his lower extremities off the bed or initiate

standing, and he required maximum assistance for bed mobility.

On HD 31, a physician noted that the family was planning for the patient’s return home.

A staff physician wrote that the patient was able to eat with assistance from his wife and

agreed with the plan to discharge the patient from inpatient care with close clinic followup. The physical therapist evaluated the patient and documented that he required

maximum assistance for transfers and bed mobility tasks. Discharge plans were made for

a hospital bed, air mattress overlay, shower chair, and wheelchair in the home. Home

Based Physical Therapy was to provide equipment training to the patient’s family and

training on transfer techniques. A home health consultation was initiated for home

physical therapy.

7 Septic shock is life-threatening low blood pressure due to overwhelming infection.
 8 A stage II pressure ulcer is a partial thickness skin loss involving the epidermis, dermis, or both. The ulcer is
 

superficial and presents clinically as an abrasion, blister, or shallow crater.

9 An air mattress overlay is a mattress specifically designed to allow for efficient air flow throughout the mattress for
 

use in the treatment and prevention of pressure ulcers. Continually changing air pressure keeps body fluids moving,
 

improving circulation. The pad feature uniform air tubes that alternately inflate every 4 minutes.
 10 A condom catheter is an external device that encircles the penis and connected to a urinary collection bag by a
 

tube.
 

VA Office of Inspector General 4 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

On HD 34, the patient was discharged to his home. The nurse noted a pressure ulcer on

the coccyx area and excoriation (skin tear) on his scrotum and penis at the time of

discharge. The following discharge instructions were provided to the family:

 Management and treatment of the pressure ulcer.

 Turning and repositioning the patient.

 Application of aloe vesta cream to the ulcer.

 Heel protection.

In early December, the patient presented to the ED with complaints of abdominal pain

and constipation. The ED physician noted large blisters on both heels despite wearing

heel supports and a pressure ulcer on the coccyx area. The ED physician treated the

constipation and discharged the patient to his home. A consult was sent for the patient to

follow up with the Wound/Ostomy Nurse at the system.

Two days later, the Wound/Ostomy Nurse responded to the consult and recommended a

complete assessment of the patient’s wounds and a nutritional assessment at the patient’s

next primary care visit.

Four days later, the patient was seen by his primary care physician in the clinic for a

follow-up appointment. The family reported the patient had no food intake or bowel

movement since the ED visit. The clinic nurse noted concern for the family’s ability to

care for the patient at home. The patient was transferred to the ED and seen by a

physician. The physician admitted the patient to the medical/surgical unit with a

diagnosis of urosepsis11 and wrote “multiple developing pressure ulcers on his lower

extremities.”

On HD 2, the patient was placed on an air mattress overlay. A nurse documented,

“patient is resting in bed currently refusing to be rolled or moved.”

On HD 3, a physician documented that the patient’s albumin level was 1.9 grams per

deciliter. The dietitian wrote to add Glucerna® (liquid nutrition) oral supplements to the

patient’s diet for extra calories and that tube feedings may be required. The nurse

documented a stage II pressure ulcer on the left heel and a stage III pressure ulcer12 on the

coccyx area and right heel. Pictures were taken and dressings applied to the wounds.

The system’s pressure ulcer protocol was initiated.

11 Urosepsis is a bloodstream infection from a urinary tract infection.
 12 A stage III pressure ulcer is a full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue.
 

The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
 

VA Office of Inspector General 5 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

On HD 4, the Wound/Ostomy Nurse saw the patient and documented multiple pressure

ulcers on the lower half of his body, overgrown toenails, and steady decline in albumin

level.

The Wound/Ostomy Nurse wrote in the treatment plan:

Continue to use the overlay mattress [air mattress overlay]; the patient’s

potential to heal is poor and has potential for further skin breakdown due to

nutritional status; keep foot wounds dry and wrap with gauze to protect; a

podiatry consult for nail care; use a pillow between knees; apply Santyl®

[an enzyme therapy used to removes necrotic tissue] to unstageable wounds

twice daily and use cover dressing; and place a foley catheter securing the

device at all times to prevent further damage to meatus.

On HD 6 the physician recommended placement of an NGT and when stable a general

surgery consult for percutaneous endoscopic gastrostomy tube13 placement; however, the

patient and family declined this intervention.

On HD 7, the family made a decision to place the patient in a nursing home where he

would be on comfort care.14 The physician documented that the family understood the

consequences and potential outcome of refusing the NGT and other aggressive medical

treatment.

On HD 10, the patient’s family decided to take the patient home instead of community

nursing home placement. The physician discharged the patient to his home and noted,

“as patient is comfort care, do not need to continue any meds [medications].”

The patient died the next day at a community regional medical center.

Inspection Results 

Issue 1: Quality of Care 

A. Patient Neglect and Physical Elder Abuse 

We did not substantiate the allegation that the patient developed pressure ulcers due to

neglect or physical elder abuse.

According to medical record documentation, the patient did not have pressure sores when

he was admitted to the system in early December. However, when the patient was a

resident in the CLC, he developed a pressure ulcer on the tip of his penis from a Foley

13 Percutaneous endoscopic gastrostomy tube is a feeding tube that provides a safe and effective way to provide
 

food, liquids, and medications directly into the stomach through a tube placed in the abdomen. 14 Comfort care is supportive treatment for patients who are suffering from a terminal illness or who refuse
 

life-sustaining treatment.
 

VA Office of Inspector General 6 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

catheter and a stage II pressure ulcer in his coccyx region most likely due to friction and

shearing forces when moving the patient. Nursing staff initiated the system’s pressure

ulcer protocol and placed the patient on a special bed to minimize the risk of further skin

breakdown.

In November 2010, when the patient was discharged to his home, he had two pressure

ulcers, one on his penis and one in his coccyx area. Four weeks later, the patient was

readmitted to the system with multiple pressure ulcers on his lower extremities.

Conclusions 

Although the patient developed pressure ulcers while in the CLC, we did not substantiate

that the pressure ulcers were the result of nursing neglect or physical abuse. We

determined that the patient was assessed for skin breakdown and pressure ulcer

interventions were initiated. The patient refused nursing care, medical treatment, food

and fluids resulting in a steady decline in his medical condition and functional mobility.

We made no recommendations.

Comments 

We made no recommendations. The VISN and Medical Center Directors agreed with our

findings.

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 7 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 26, 2011

From:	 Director, Sierra Pacific Network (10N21)

Subject:	 Healthcare Inspection – Patient Neglect and Abuse, VA Central 

California Health Care System, Fresno, California 

To:	 Director, San Diego Office of Healthcare Inspections (54SD)

Thru:	 Director, Management Review Service (10B5)

1. Thank you for the opportunity to review the draft report

of a review that took place in March 2011 regarding an

allegation of patient neglect and abuse at VA Central

California Health Care System, Fresno, CA. I am pleased

your review did not substantiate this allegation.

2. I know the facility appreciated the professional manner

with which the team conducted the review.

3. Should you have any further questions please feel free to

contact Terry Sanders, Associate Quality Manager for

VISN 21.

(original signed by:) 

Sheila M. Cullen
 

Director, VA Sierra Pacific Network (10N21)
 

VA Office of Inspector General 8 
Abuse, VA Central California Health Care System, Fresno, California

enter Director Comments

l California Health Care System (570/00)

pection

h Care System, Fresno, California

Pacific Network (10N21)

e the opportunity to provide our input on the

re Inspection which took place

.

so like to express our thanks to the OIG

visited our facility. We found the team

ul and fair throughout our preparatory

as during the inspection itself.

there was no evidence to substantiate claims

or physical abuse.

CHE

l California Health Care System (570/00)

Patient Neglect an Fresno, California

Medical

Department

Veterans Affa

4,

VA

Healthcare Central

California

VA

We appre

VA OIG

23,

ld

review team

members very y

activities as

3. In the patie

the findings

of nursing

Alan S. Perry,

, VA

Patient Neglect and Abuse, VA Central California Health Care System

Memorandu

VA Central California Health Care System (570

, V

We appreciate the opportunity to provide our input on t

VA OIG Healthcare Inspection which took

ld also like to express our thanks to the

review team which visited our facility. We found the

members very helpful and fair throughout our prepa

reviewed, we concur

the findings that there was no evidence to substantiate clai

, VA Central California Health Care System (570

Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

Medical Center Director Comments 

Appendix B 

Department of 

Veterans Affairs 

of 

irs Memorandum 

Date: August 24, 2011

From: Director, VA Central California Health Care System (570/00)

Subject: Healthcare Ins 

California Healt 

Inspection – Patient Neglect and Abuse, VA 

Health Care System, Fresno, California 

A Central 

To: Director, VA Sierra Pacific Network (10N21)

1. We appreciat

VA OIG Healthca

March 21-23, 2011

ciate the opportunity to provide our input on the

Healthcare Inspection which took place

2011.

he

place

2. We would al

review team which

members very helpf

activities as well

also like to express our thanks to the OIG

which visited our facility. We found the team

helpful and fair throughout our preparator

well as during the inspection itself.

OIG

team

ratory

3. In the patient

the findings that

of nursing neglect

nt’s case which was reviewed, we concur with

that there was no evidence to substantiate claims

neglect or physical abuse.

with

ms

Alan S. Perry, FACHE
 

Director, VA Central California Health Care System (570/00)
 

VA Office of Inspector General 9 
Patient Neglect and Abuse, VA Central California Health Care System, Fresno, California 

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 Deborah Howard, RN, Project Leader

Judy Montano, MS, Team Leader

Stephanie Hills, RN

Robert Yang, MD

Derrick Hudson, Program Support Assistant

VA Office of Inspector General 10 
Alleged Quality of Care Issues, VA Central California Health Care System, Fresno, California 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VA Sierra Pacific Network (10N21)

Director, VA Central California Health Care System (570/00)

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: Barbara Boxer, Dianne Feinstein

U.S. House of Representatives: Dennis Cardoza, Jim Costa, Devin Nunes, Jeff Durham

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

VA Office of Inspector General 11