Coatesville VA Cited for Care Lapses

By Walter F. Roche Jr.

Patients in a Veterans Administration facility in Coatesville, PA suffered serious falls and failed to get proper medication or pain assessments, according to a 35-page report from the VA Inspector General.
The report issued this week found the lapses in a three unit community living center, which includes long term patients and a locked dementia unit.
The critical auditors report was based on two 2019 visits to the 126-bed facility following complaints that improper nursing care was the cause of multiple deficiencies. The auditors said they were unable to confirm that poor nursing care resulted in harm to patients, but they did find multiple lapses in a review of dozens of patient records.
The cases reviewed include a veteran in his 70s who died not long after suffering a fall and another patient who died after falling down a flight of stairs in a wheelchair.
The report states that a review of records showed that in 32 of 75 records there was no records of a required post-fall assessment.
Among the deficiencies cited was the failure by staffers to document the condition of patients before and after medication was administered as ordered by a physician.
"This increases the risk for poor patient outcomes including unnecessary side effects," the report states.
Other records showed a failure to record pain assessments, thus risking over or under medication.
The review, which was initially limited to a dozen patient records, was ultimately expanded to include eight more.
Also cited was the inaccessibility of patient call buttons and an allegation that the failure by staffers to respond to call buttons resulted in a fall by a patient who needed to go to the bathroom. Auditors found that six of 14 call bells were in fact inaccessible.
The auditors also found that equipment used to safely lift patients in or out of bed was inoperable.
In 32 of 33 records reviewed on patients who needed to be turned or toileted there was no documentation that those services had been provided.