Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Review of Alleged Institutional 

Mistreatment / Mismanagement 

of 

Geriatrics and Extended Care Patients 

VA Medical Center 

Coatesville, Pennsylvania 

Report No. 06-00008-237 September 29, 2006

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

VA Office of Inspector General i 

Executive Summary 

The purpose of this inspection was to determine the validity of multiple allegations 

pertaining to patient care issues in the Geriatrics and Extended Care Service (G&ECS) of 

the Coatesville, PA VA Medical Center. These allegations included alleged 

unanticipated deaths, patient abuse, privacy violations, and poor quality of care. In all, 

over 100 separate allegations were made by the complainant; we grouped them by 

category as follows: 

Unanticipated Patient Deaths. We concluded that while patient deaths during the time 

period in question were not necessarily expected, the patients in question had 

compromised medical conditions. The deaths were not unanticipated and were not the 

result of poor care. 

Patient Abuse. We found that instances of patient abuse had occurred in the past on the 

units in question. However, appropriate corrective actions had been taken to address this 

critical problem, and we found no current evidence of patient abuse. 

Communication. There were multiple complaints alleging communication problems and 

patient privacy violations. Management has already taken action to improve 

communications; we found no evidence of patient privacy violations. 

Staff Competencies. We concluded that unit staff had the appropriate competencies to 

treat patients admitted to, and cared for by, the G&ECS. 

Environment of Care. We concluded that the G&ECS environment of care is clean and 

sanitary and that food and beverages served are not out of date. We concluded that there 

were delays for equipment repairs, but medical center managers have taken actions that 

have reduced these delays. 

Information Technology Issues. We substantiated the allegation that the content of a 

signed medical record progress note can be altered by another individual, deleted, or 

made hidden to the end user. We concluded that this is an unacceptable electronic 

medical records vulnerability and patient safety issue. Upon further exploration, our 

concern is that the issue of inadequate compliance with the policy is system-wide in 

nature and not simply local. 

Recommendation: We made a recommendation that the Under Secretary for Health 

should ensure that all Veterans Health Administration (VHA) medical facilities are in 

compliance with VHA Handbook 1907.1, Health Information Management and Health 

Records. The Under Secretary concurred and submitted appropriate implementation 

plans. We will follow up on planned actions until they are completed. 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Services Network 4 (10N4)

Director, Coatesville VA Medical Center (00) 

Under Secretary for Health (10) 

SUBJECT: Healthcare Inspection – Review of Alleged Institutional Mistreatment / 

Mismanagement of Geriatrics and Extended Care Patients, VA Medical 

Center, Coatesville, Pennsylvania. 

Purpose

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

received multiple allegations pertaining to patient care issues on the Geriatrics and

Extended Care Service (G&ECS) of the Coatesville, PA, VA Medical Center (VAMC or 

medical center). These allegations were extensive and included alleged unanticipated

deaths, patient abuse, patient privacy violations, inadequate communication with patient 

family members, poor quality of care, patient safety concerns, medical records 

documentation failures, medical records alterations, and an alleged unsatisfactory

environment of care. 

The purpose of this inspection was to determine the validity of these allegations. 

Background 

The medical center is a 533-bed specialty referral facility that provides treatment for 

substance abuse, post-traumatic stress disorder, chronic mental illness, homelessness,

women’s health, and dementia. On October 5, 2005, a complainant alleged to the VA

OIG numerous deficiencies in patient care and medical center management. In all, over 

100 allegations were made. 

The overall themes of the allegations were those of alleged institutional mistreatment of 

patients and alleged deficiencies in patient care. They may be categorized as follows: 

• Unanticipated Patient Deaths – The complainant alleged that there were over 40 

unanticipated deaths that occurred on 2 of the medical center’s G&EC Units over 

a 2–3 year period. 
Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

• Patient Abuse – The complainant alleged multiple instances of patient-on-patient 

assault and staff-on-patient assault. The complainant alleged that the medical 

center’s Psychiatric Emergency Assistance Team was called inappropriately to 

force patients to take medications and that G&EC staff withheld privileges when 

patients refused to conform to unit policies. It was alleged that management did 

not intervene to stop patient abuse or support G&EC staff who attempted to report 

patient abuse. 

• Communication Issues – There were multiple complaints alleging patient privacy 

violations. There were also allegations of poor communication by G&EC staff 

with patients and their families and between G&EC leadership and staff. 

• Staff Competencies – It was alleged that some G&EC staff lacked necessary 

knowledge concerning patients’ disease processes. 

• Environment of Care Concerns – It was alleged that the G&EC unit was dirty, that 

there were deficiencies in infection control practices, that food and beverages 

served to patients were outdated, and that there were delays in equipment repair. 

• Information Technology Issues – It was alleged that signed progress notes in the

electronic medical record may be altered by individuals other than the note’s 

original author. Such individuals may allegedly include cosigners. Further, it was 

alleged that medical center personnel with certain computer access privileges may

delete from the electronic medical record a signed progress note or that they may 

hide it from the end user. 

• Other Issues – It was alleged that G&EC employees are excessively loud during 

night shift. Also, it was alleged that a social worker had inappropriately 

committed patient funds without proper authorization. 

Scope and Methodology 

A review of each one of over a hundred allegations was beyond the scope of this review 

and exceeded the resources available to OHI. However, analysis revealed common 

themes. The allegations were grouped and addressed in the context of the broad 

categories discussed above. 

The allegation regarding a social worker inappropriately committing patient funds 

without proper authorization was reviewed by the OIG and referred to the VAMC for 

administrative action. VAMC managers took appropriate action; we do not discuss this 

issue further. 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

On October 31, 2005, we conducted a telephone interview with the complainant in order 

to clarify the initial written allegations received by OIG. On November 3, we 

interviewed the complainant in person to further clarify the multiple allegations. 

On December 12, at 5:30 a.m., we made an unannounced site visit to the medical center. 

We inspected the two long-term care units in question. We also interviewed staff and 

patients and reviewed medical records. Over the next 3 days, we made additional

unannounced visits to the units, conducted interviews with patients, patients’ family

members, and staff. We interviewed medical staff responsible for maintaining the 

Information Security/Computerized Patient Record System (IS/CPRS). We obtained 

copies of the business rules regarding IS/CPRS and we conducted a test of CPRS to assist 

in determining whether the information technology allegations were valid. 

On January 5, 2006, two healthcare inspectors interviewed the former Director for 

G&ECS who had been in that position during the time the majority of the complainant’s 

alleged incidents occurred. 

On January 8–11, we conducted a second site visit. We started the site visit on a Sunday,

in order to optimize the availability of patient family members for interview and to

inspect the units in question on a weekend day. During this second site visit, we

interviewed additional staff. We also reviewed multiple documents, including personnel 

records, administrative investigation reports, root cause analyses reports, medical records, 

long-term care meeting minutes, unit and facility policies and procedures, and a 

December 2005 surveillance tape that showed an instance of staff-on-patient abuse. 

The inspection was conducted in accordance with the Quality Standards for Inspections

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

Findings and Conclusions

1. Allegation: Unanticipated Patient Deaths

This allegation was not substantiated. 

The complainant provided the names of 40 patients who died on the 2 long-term-units 

during a 3-year period, alleging that a number of the deaths seemed unanticipated by 

staff. The complainant related some of these deaths to a flu epidemic in 2003 and 

suggested that some of these deaths may have occurred due to poor care. 

OHI nurses and a physician reviewed the medical records of all 40 of the named patients. 

We found that the average age of these patients was 80 years; most had do-not-resuscitate 

orders; and all had complex medical conditions. We found no indication that patients’

deaths resulted from poor care, inappropriate care, or from foul play. 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

We confirmed that there had been a flu outbreak in 2003 and that seven patients on the

two long-term-care units in question had died in this time period. We found that at the 

time of the outbreak, medical center clinicians took appropriate infection control actions. 

One of these was a patient quarantine on both units in an attempt to limit exposure. 

Overall, we found that several deaths that were attributable to flu in elderly, 

compromised patients; other patient deaths, while not necessarily expected at precisely 

the time of occurrence, were not unanticipated. 

Conclusions and Discussion Regarding: Unanticipated Patient Deaths

We concluded that while all patient deaths on the G&ES units during the time period in 

question were not necessarily expected at the time of occurrence, the patients in question 

had compromised medical conditions and death was not unanticipated. Several deaths 

did occur as a result of a flu outbreak. We concluded that the complainant was correct in 

identifying inpatient deaths and in relating some of these deaths to a flu epidemic in

2003. However, the larger context of the allegation—that either the flu deaths or others 

were due to poor care—does not have merit. 

2. Allegation: Patient Abuse

The allegation of past patient abuse on long-term-care units at the medical center is 

substantiated. However, we did not substantiate the implication that medical center 

managers allowed abuse to continue unchecked or uninvestigated. 

The complainant gave us a list of names of patients who had allegedly been abused and 

the names of medical center staff allegedly involved in this abuse. The complainant told 

us that medical center staff did not properly intervene when patients were abusing other 

patients. 

The complainant alleged that due to staffing issues there was diminished staff supervision 

and accountability. The complainant alleged that staff yelled at, cursed, and threatened 

patients if they refused to take their medication(s) or be cooperative. The complainant 

alleged that patient privileges were withheld for minor unit rule infractions and that 

patients were not dressed appropriately for prevailing weather. The complainant further 

alleged that several patients suffered head injuries as a result of patient-on-patient

assaults and alleged prejudicial actions by certain staff. 

We found that in August 2002, medical center managers became aware that a culture of 

abuse existed on the units in question. They took actions to change this culture. An 

Administrative Board of Inquiry was conducted to review incidents of alleged patient 

abuse and the following actions were taken:

• Some staff were fired and other staff were reassigned. 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

• One staff member was arrested because of observed patient abuse. 

• Increased professional staff were employed, including a social worker,

psychologist, and a geropsychiatrist. 

• Staff supervision lines were restructured. Existing staff on the units had to reapply 

for their positions. 

• Both units were remodeled, and surveillance cameras were installed in order to 

improve the monitoring of patients and staff. 

• All staff were required to attend “Culture Change” lectures that centered on the 

appropriate relationship between caregiver and the patient.

During our inspection, we interviewed numerous patient family members and unit staff to 

assess the current unit culture. Patient family members told us that they were pleased

with the care their family members were receiving. Many felt that the ambience on the 

remodeled units was homelike and quiet. Having open visiting hours was appreciated, 

and many felt that communication with staff had improved. We were told that staff were 

now encouraging family members to attend regularly scheduled patient treatment 

meetings. 

We interviewed both new staff and staff who were employed on the units when the

documented instances of patient abuse had occurred. Generally, staff told us that the 

culture on the units had improved. They told us that new unit management teams were 

more responsive to their needs and included staff in decisions regarding patient care and

unit policies. They felt the culture of the units was patient-centered and emphasized both 

patient and staff safety. 

We did not observe any incidents of patient abuse during our multiple visits—including 

unannounced visits—to the units. We reviewed patient incident reports from fiscal year 

2003 through February 2006 and found six reports of alleged patient abuse. Medical 

center managers had reviewed all six incidents; they took appropriate corrective actions

in each to include suspensions, terminations, and removal from patient care. 

We were shown a surveillance tape that showed a possible incident of staff-on-patient 

abuse. Managers had reported this incident to the local police, removed the employee

from direct patient care, and conducted a Board of Inquiry. 

Conclusions and Discussion Regarding: Patient Abuse

While we concluded that instances of patient abuse had occurred in the past on the units 

in question, appropriate corrective actions had been taken to address this critical problem. 

We concluded that at present, processes are in place to detect, report, and address

VA Office of Inspector General 5 
Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

potential incidents of patient abuse; we found no evidence that a pattern of patient abuse 

is occurring presently. 

3. Allegation: Communication Issues

We substantiated several of the complainant’s allegations concerning poor

communication. 

The complainant alleged that staff violated patients’ privacy rights, alleging that medical 

center staff discussed patient’s private information (behaviors and diagnoses) in front of

other patients and gave copies of patients’ treatment plans to family members without

proper authorization. The complainant alleged that staff wrote derogatory descriptions of 

patients in the medical records and did not document all medications that patients 

received. The complainant also alleged that patient family members were excluded from 

patient treatment meetings and were prevented from visiting patients. 

We substantiated that some staff used inappropriate language in the patient’s medical 

records. However, medical center mangers were aware of this issue and had taken 

appropriate corrective actions against the involved staff. We also found that in 2003

some family members were not invited to attend patient treatment planning meetings and 

at times were not allowed on the unit to visit the patients. However, the new culture on 

the units is to encourage family members to attend treatment planning meetings and to 

promote open visitation. 

While we substantiated that staff gave copies of patient treatment plans to family 

members, we did not substantiate the implication that it was a violation of the patients’

privacy rights. It is not a privacy violation to give copies of treatment plans to family 

members who participated in the patient treatment meeting during which the plan was 

developed, as was the situation in the instances that came to our attention. 

Conclusions and Discussion Regarding: Communication Issues

We were unable to substantiate or refute whether staff in the past discussed patient’s 

private information inappropriately or failed to document all medications that patients

received due to the lapse in time from the alleged actions. 

4. Allegation: Staff Competencies

We did not substantiate the allegation that unit staff was not competent to treat their 

patients. 

The complainant alleged that staff lacked sufficient knowledge regarding dementia to 

give effective care to patients in the G&EC unit. Specifically, it was alleged that many 

G&EC staff were not able to recognize symptoms of co-morbid medical conditions that 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

should then be communicated to a registered nurse or physician; therefore, patients did

not always receive the appropriate treatment. 

An OHI physician who is a Board-certified geropsychiatrist and two OHI registered 

nurses reviewed the medical records of patients from several sources: a list provided by 

the complainant, cases noted in Pharmacy and Therapeutics Committee meeting minutes, 

and patient incident reports. We did not find any evidence of medical conditions that 

went undiagnosed or untreated. We also reviewed the credentialing and privileging files 

of unit staff and found that they had appropriate training and credentials for their assigned 

duties. 

With regard to the general issue of staff competencies, the medical center’s Chief Nurse 

Executive told us that over the last 3 years, the units had frequent turnovers in

management. This had a negative impact on the consistency and quality of unit 

leadership and accountability of unit staff. The unit managers at the time of our 

inspection have been in place for approximately 6 months; senior managers, unit staff, 

and patient family members all reported their overall perceptions that patient care and 

staff morale have significantly improved. 

Conclusions and Discussion Regarding: Staff Competences

Overall, we concluded that unit staff had the appropriate competencies to treat patients 

admitted to, and cared for by, the two units in question. 

5. Allegation: Environment of Care

We substantiated that there were delays for equipment repairs. We did not substantiate 

that the two G&EC units in question were dirty. We could neither substantiate nor refute 

that patients were served outdated food and beverages in the past, but we did not

substantiate that patients were served outdated food and beverages at present. 

The complainant alleged long delays for equipment repairs. We reviewed the equipment 

work orders for both units for the last year. The medical center goal is to have all 

equipment repair orders completed within 30 days. However, we found several work 

orders that showed delays of 60 to 90 days. Medical center managers were aware of this 

problem and provided documentation to support improved timeliness for equipment 

repairs over the last year. 

The complainant also alleged that the units were dirty. Specifically, it was alleged that 

furniture was not routinely and appropriately cleaned and that bathrooms were generally 

dirty with a foul odor. 

We inspected both units multiple times on all shifts. Our inspections were both 

unannounced and announced, on weekdays and weekends. We also interviewed 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

housekeeping managers and staff and reviewed their training records. Our inspection

revealed the units to be clean and sanitary. The units were generally free of foul odors.

Housekeeping training records contained documentation that the cleaning staff had 

received required training. 

With regard to the allegation that outdated food and beverages were served to patients, 

we interviewed dieticians and inspected refrigerators and patient trays for outdated food 

and beverages. We did not find any outdated food or beverages in the refrigerators or on 

patient trays. We also observed that dietary workers checked refrigerators on both units

for expiration dates every shift. 

Conclusions and Discussion Regarding: Environment of Care

We concluded that the unit environment of care is clean and sanitary, and that food and

beverages served are not out of date. We concluded that there were delays for equipment 

repairs and that medical center managers have taken actions that have reduced these 

delays. 

6. Allegation: Information Technology Issues

We substantiated the allegation that the content of a signed medical record progress note 

can be altered by another individual, such as a cosigner. We also substantiated that 

personnel with certain computer access privileges can delete a signed progress note or 

make it hidden to the end user. 

The complainant alleged that a required cosigner deleted or had deleted numerous lines 

of a progress note after the complainant had signed it. At the other VA medical centers 

where the complainant had worked, the complainant reported that if a required cosigner

had changes to signed reports, the cosigner affixed an addendum with the information, 

leaving the original report as written. 

We reviewed Veterans Health Administration (VHA) and medical center information 

technology policies and interviewed Information Resource Management Service staff. 

We found that the problem described above by the complainant was indeed valid; it had 

also been recognized at both local and national VA levels. We learned a communication 

(a software patch) had been sent from the VHA Office of Information (OI) on 

October 20, 2004, to all VAMCs; it addressed a number of issues relating to the editing 

of signed documents. The patch stated that “the practice of editing a document that was 

signed by the author might have a patient safety implication and should not be allowed.” 

Business rules define what functions certain groups or individuals are allowed to perform

in the medical record. We found that the medical center had business rules that were in 

clear violation of VHA policy as follows: 

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Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

1. An uncosigned progress note may be edited by a clinical coordinator. 

2. An uncosigned progress note may be edited by a PC Team A leader. 

3. An uncosigned progress note may be edited by a physician leader. 

4. An uncosigned progress note may be edited by a Chief, Medical Information 

Service. 

The patch directed medical center managers to remove business rules that allow expected 

cosigners to edit signed and uncosigned documents. 

Due to the seriousness of this situation, in January 2006 the OIG initiated a formal 

inquiry to VHA. In response to this inquiry, VHA’s OI completed an analysis of 

business rules on this topic at 122 VA medical centers in order to determine whether nonsanctioned employees (anyone other than the Privacy Officer) had the ability to edit 

signed medical documents. According to a memorandum to the OIG from VHA’s Chief 

Information Officer, OI reviewed a total of 2,947 business rules for the 122 facilities. OI 

found that 37 percent of the 122 VAMCs had not deleted the business rules described 

above as directed by the patch. OI additionally told OIG, “...[E]vidence exists that 

facilities have created local business rules that permit personnel other than the Privacy 

Act Officer to edit a document in a signed state.”1

 OI recommended institution of a 

VHA-wide software change that limits the ability to edit a signed medical record 

document to the facility’s Privacy Officer. 

Conclusions and Discussion Regarding: Information Technology Issues

We substantiated the allegation that the content of a signed medical record progress note 

could be altered by another individual, such as a cosigner, and concluded that this is

system vulnerability ripe for exploitation or malfeasance. We also substantiated that 

personnel at the medical center with certain computer access privileges could delete a 

signed progress note or make it hidden to the end user. We concluded that this is an 

unacceptable electronic medical records vulnerability and patient safety issue. 

The relevant policy that addresses the issues surrounding basic procedures for managing 

the patient health record is contained in VHA Handbook 1907.1, Health Information 

Management and Health Records. Upon further exploration, our concern from the

findings at the Coatesville VAMC is that the issue of inadequate compliance with the 

policy is system-wide in nature and not simply local. 

 1

 Department of Veterans Affairs Memorandum dated April 3, 2006, from the VHA Chief Information Officer to the

Director, Management Review Service, through the VHA Chief of Staff, sent to OIG by fax April 4, 2006.

VA Office of Inspector General 9 
Review of Alleged Institutional Mistreatment/Mismanagement of Geriatrics and Extended Care Patients 

Recommendation 

The Under Secretary for Health should ensure that all VHA medical facilities are in 

compliance with VHA Handbook 1907.1, Health Information Management and Health 

Records. 

Under Secretary for Health Comments 

The Under Secretary for Health concurred with all findings. With regard to the 

recommendation for managing patient health records, VHA concurred, with

consideration of the following actions having been taken: 

1. Coatesville VAMC’s Business Rules #2 & #3 (see page 9) were removed at the 

time of the investigation. 

2. Coatesville VAMC’s Business Rules #1 & #4 (see page 9) have been removed and 

were replaced by: “An UNCOSIGNED PROGRESS NOTE may only be edited 

by the PRIVACY ACT OFFICER, or Designee. The Privacy Act Officer 

approves the designation of the Clinical Applications Coordinators to the User 

Class of Privacy Act Officer for the sole purpose of changing the cosigner of an 

uncosigned note.” 

3. If a note needs to be altered this does not occur without the approval of the Privacy 

Officer per VHA Handbook 1907.1 (reference page 27, (3) “No edit or alteration 

of any documentation after manual or electronic signature has been completed can 

occur without approval of HIM professional or Privacy Officer”). 

Office of Inspector General Comments 

The Under Secretary for Health agreed with the findings and recommendation and 

provided acceptable implementation plans. (See Appendixes A and B, pages 11–19 for 

the complete text.) We will follow up on planned actions until they are completed. 

 (original signed by:)

JOHN D. DAIGH, JR, M.D. 

Assistant Inspector General for 

Healthcare Inspections 

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Appendix A 

Under Secretary for Health Comments

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Appendix B 

 

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Appendix C 

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VA Office of Inspector General 16 
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VA Offic VA Office of Inspector General tor General 17 
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VA Offic VA Office of Inspector General tor General 18 
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Appendix D 

OIG Contact and Staff Acknowledgments 

OIG Contact Gail Bozzelli, Healthcare Inspector 

Regional Office of Healthcare Inspections 

Washington, DC – (202) 565-4505 

Acknowledgments Nelson Miranda, Director 

Randall Snow, Associate Director 

Donna Giroux 

Carol Torczon 

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Appendix E 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 4 

Director, Coatesville VA Medical Center 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Quality of Life and Veterans Affairs 

House Committee on Government Reform

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Joseph R. Biden, Thomas Carper, Frank Lautenberg, Robert Menendez, 

Rick Santorum, and Arlen Specter 

U.S. Representatives: Robert A. Brady, Charles W. Dent, Michael Fitzpatrick, James W. 

Gerlach, Tim Holden, Joseph Pitts, and Curt Weldon 

 

 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/52/reports/mainlist.htm. This report will remain on the OIG Web 

site for at least 2 fiscal years after it is issued. 

VA Office of Inspector General 21