Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Nursing Quality of Care 

Issues 

Edward Hines Jr. VA Hospital 

Hines, Illinois 

Report No. 09-02449-01 October 2, 2009 

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Executive Summary 

The purpose of this inspection was to determine the merit of allegations made by an 

anonymous complainant alleging that the following incidents occurred on one nursing 

unit in a 3–4 week period prior to April 27, 2009, at the Edward Hines Jr. VA Hospital. 

•	 On two occasions, nurses attempted to administer a medication to a patient who was 

allergic to the medication. 

•	 A nurse failed to remove a tourniquet from a patient who was diagnosed with 

dementia. 

•	 A patient with large wounds on the buttocks was left lying in feces because the nurse 

called to the bedside said the next shift should clean the patient. 

We substantiated that two nurses attempted to administer a medication for which the 

patient had a documented allergy. However, we found that nursing and the supervising 

physician took appropriate corrective actions. The nursing staff never administered the 

medication, which was discontinued prior to the next scheduled administration. 

We substantiated that a nurse failed to remove a tourniquet from the arm of a patient with 

dementia. However, we found that nurse managers took appropriate actions and 

adequately addressed the issue. 

We did not substantiate that a patient with large wounds on his buttocks was left lying in 

feces or that the nurse told the patient that the next shift should clean and dress the 

wounds. 

Although we substantiated two of the three allegations, we concluded that clinical 

managers took appropriate administrative actions prior to our review. We made no 

recommendations. 

VA Office of Inspector General i 
 

DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General 

Washington, DC 20420 

TO:	 Director, VA Great Lakes Health Care System (10N12) 

SUBJECT:	 Healthcare Inspection – Alleged Nursing Quality of Care Issues 

Edward Hines Jr. VA Hospital, Hines, Illinois 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections (OHI) 

reviewed allegations regarding the quality of nursing care on a unit the Edward Hines Jr. 

VA Hospital (the hospital). The purpose of this inspection was to determine whether the 

allegations had merit. 

Background 

The hospital is a tertiary care facility located 12 miles west of downtown Chicago, IL. 

The hospital offers acute medicine, surgery, primary care, extended care, and acute and 

outpatient psychiatry services. Specialized clinical programs include blind rehabilitation, 

spinal cord injury, neurosurgery, radiation therapy, and cardiovascular care. The hospital 

affiliates with Loyola University's Stritch School of Medicine and the University of 

Illinois College of Medicine at Chicago. It is part of Veterans Integrated Service 

Network (VISN) 12. 

An anonymous complainant contacted OIG's Hotline Division on May 5, 2009, alleging 

that the following incidents occurred on one nursing unit in a 3–4 week period prior to 

April 27, 2009: 

•	 On two occasions, nurses attempted to administer a medication to a patient who was 

allergic to the medication. 

•	 A nurse failed to remove a tourniquet1

 from the arm of a patient diagnosed with 

dementia. 

•	 A patient with large wounds on the buttocks was left lying in feces because the nurse 

called to the bedside said that the next shift should clean the patient. 

The complaint was forwarded to OHI on June 17, 2009. 

1

 A device, typically a tightly encircling bandage used to dilate veins before blood is drawn. 

VA Office of Inspector General 1 
Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Scope and Methodology 

We conducted a site visit on August 10–14, 2009. During the visit, we interviewed the 

Associate Director for Patient Care Services (ADPCS), the Associate Chief Nurse 

(ACNS) Inpatient Care, clinicians, the nurse manager, and unit nursing staff. In addition, 

we interviewed patients currently on the unit as well as two of the patients named by the 

anonymous complainant. We were unable to reach one patient or the patient's family. 

We also conducted reviews of medical records, patient incident reports, and complaints 

for the unit. We reviewed staffing schedules and daily staffing reports for the unit from 

October 2008–July 2009. 

We conducted the inspection in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency. 

Inspection Results 

Issue 1: Safe Medication Administration 

We substantiated that two nurses attempted to administer a medication for which the 

patient had a documented allergy. However, we found that nursing and the supervising 

physician took appropriate corrective actions. 

We interviewed the ADPCS, the ACNS, the nurse manager, the nurse involved with the 

initial administration attempt, and the patient. We also interviewed the service chief who 

supervised the resident physician who ordered the medication for the patient. We 

reviewed the patient's medical record and Bar Code Medication Administration (BCMA) 

records during the time of the patient's admission. We found appropriate documentation 

of the medication allergy in the Computerized Patient Record System (CPRS). 

The nurse involved in the initial attempt to administer the medication told us that 

medication administration procedures require verification of medication allergies in the 

Crisis Notes, Warning Notes, Allergies, and Directives (CWAD) section of CPRS during 

medication administration. However, verification of patient allergies in the CWAD did 

not occur for this patient during the administration procedure in question. The nurse 

became aware of the allergy when the patient asked the nurse to identify the medications 

prior to accepting them. The patient informed the nurse of an allergy to one of the 

medications, and refused the dose. 

The nurse notified the physician caring for the patient and documented the information in 

a nursing progress note. The nurse told us that the information was conveyed to the 

oncoming shift. Despite this communication, a nurse on the next shift attempted to 

administer the same medication to the patient. However, when the patient relayed being 

allergic to the medication, the nurse did not administer the dose. 

VA Office of Inspector General 2 
Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

The supervising physician told us that the order for the medication had triggered an alert 

to the resident who ordered the medication regarding a medication allergy; however, the 

resident chose to override the alert without comment and continued with the order. The 

pharmacist also received an alert, placed a notation in the record that the resident was 

notified of an allergy, and processed the order. Of note, nursing staff do not receive 

allergy alerts when verifying orders in CPRS or when scanning medications or patient 

armbands in BCMA. The patient did not receive the medication, and the nurse caring for 

the patient took the appropriate action of notifying the resident that the patient had an 

allergy to the ordered medication. 

The resident and the supervising physician both spoke with the patient regarding the 

incident, and the resident discontinued the medication prior to the next scheduled 

administration. In addition, supervising physician took appropriate administrative action. 

The patient related to us that, outside of the medication incident, there were no 

complaints regarding the nursing or medical care received while an inpatient during the 

April 2009 admission or during previous admissions. 

Issue 2: Phlebotomy Protocol 

We substantiated that a nurse failed to remove a tourniquet from the arm of a patient with 

dementia. However, we found that nurse managers took appropriate actions and 

adequately addressed the issue. 

We interviewed senior managers, the nurse manager, the charge nurse at the time of the 

incident, and the nurse who found the tourniquet on the patient's arm. The nurse caring 

for the patient stated that while doing rounds on assigned patients shortly after midnight, 

it was noted that the left arm of the patient was very swollen. After further investigation, 

the nurse found a tourniquet on the patient's arm. The nurse notified the charge nurse, the 

nursing supervisor, and the physician on duty. The nurse also reported that the patient 

was confused but did not complain of pain when questioned. The physician saw the 

patient at the bedside and ordered the nurse to elevate the limb on a pillow. 

The nurse caring for the patient on the previous shift drew blood from the patient for 

testing at approximately 7:00 p.m. and mistakenly left the tourniquet in place when the 

procedure was complete. The nurse manager took appropriate administrative action. We 

were unable to contact the patient or the patient's family, but the medical record did not 

indicate any permanent injury to the patient because of the incident. 

Issue 3: Wound Care 

We did not substantiate that a patient with large wounds on the buttocks was left lying in 

feces or that the nurse told the patient that the next shift should clean and dress the 

wounds. 

VA Office of Inspector General 3 
Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

We interviewed senior managers, the nurse manager, wound care specialists, and the 

nurse thought to be involved in this complaint. The nurse recalled only one incident 

involving the named patient. The nurse related that on one occasion the patient became 

verbally belligerent when the nurse attempted to change the patient’s dressing 15 minutes 

prior to the scheduled time. The nurse left without changing the patient’s dressing and 

notified the supervisor and the unit charge nurse of the incident. 

The wound care specialists and the nurse told us that the patient was continent while on 

the unit. In addition, there was no evidence in the patient's medical record that the patient 

was incontinent of urine or feces or that the dressing required frequent changing due to 

soiling while on the unit. The wound care specialists told us that the patient's wound 

healed well with no complications, and the wound care for the patient was within the 

standard of care. During our interview, the patient expressed satisfaction with the 

nursing care and the medical care provided while on the unit. The patient did not recall 

this incident or any other incident with nursing staff. 

Additional Review Areas 

We found that reported nurse staffing on all shifts met established standards on the unit 

for the period covered by the allegations, and patient incident reports for May 1, 2008, 

through June 30, 2009, revealed no trends related to poor nursing care. The patient 

advocate reports for the unit from October 2008 through April 2009 did not reflect a high 

complaint rate related to poor nursing care and included many compliments from patients 

of the nursing care received. 

Conclusions 

Although we substantiated two of the three allegations, we concluded that clinical 

managers took appropriate administrative and corrective actions with the staff involved 

prior to our investigation. We also concluded that staffing during the time period met 

unit standards, and patient complaint data revealed no negative trends related to nursing 

care. We made no recommendations. 

Comments 

The VISN Director and Hospital Director agreed with the findings and conclusions. (See 

Appendixes A and B for the Directors' comments.) 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 4 
 

 

Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 18, 2009 

From: Network Director, VA Great Lakes Healthcare System (10N12) 

Subject: Healthcare Inspection – Alleged Nursing Quality of Care Issues, 

Edward Hines Jr. VA Hospital, Hines, Illinois 

To: Assistant Inspector General for Healthcare Inspections 

I have reviewed your report regarding the above investigation at the 

Edward Hines, Jr. VA Hospital and I concur with your findings. 

Jeffrey A. Murawsky, MD 

VA Office of Inspector General 5 
 

Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Appendix B 

Acting Hospital Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 18, 2009 

From: Acting Director, Edward Hines Jr. VA Hospital (578/00) 

Subject: Healthcare Inspection – Alleged Nursing Quality of Care Issues, 

Edward Hines Jr. VA Hospital, Hines, Illinois 

To: Assistant Inspector General for Healthcare Inspections 

We, at Edward Hines, Jr. VA Hospital, have reviewed the findings from the 

report of the above subject investigation; and we concur with your findings. 

Robert H. Beller, FACHE 

VA Office of Inspector General 6 
 

Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Jeanne Martin, PharmD, Associate Director 

Bedford Office of Healthcare Inspections 

(603) 222-5872 

Acknowledgments Glen L. Pickens, Sr., BSN 

VA Office of Inspector General 7 
 

Alleged Nursing Quality of Care Issues, Edward Hines Jr. VA Hospital, Hines, IL 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Healthcare System (10N12) 

Acting Director, Edward Hines, Jr. VA Hospital (578/00) 

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: Roland W. Burris, Richard J. Durbin 

U.S. House of Representatives: Danny Davis 

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

VA Office of Inspector General 8