No Major Faults Found in Review of VA Centers; Recommended Changes Did Not Affect Patient Care or Outcomes

By Bernhard, Blythe | St Louis Post-Dispatch (MO), November 1, 2012 | Go to article overview

No Major Faults Found in Review of VA Centers; Recommended Changes Did Not Affect Patient Care or Outcomes


Bernhard, Blythe, St Louis Post-Dispatch (MO)


After years of citations for poor patient care, federal investigators found no major faults with the St. Louis VA Health Care System in an annual survey of the John Cochran and Jefferson Barracks medical centers.

The hospitals scored good marks for their leadership, painkiller management and colon cancer screening programs, according to the report released Wednesday from the Department of Veterans Affairs.

Investigators from the departments Office of the Inspector General found problems with cleanliness, training and safety during their July visit to the sites.

Nearly half of the clinical areas inspected had dirty exam rooms, soiled linens or holes in the walls. Fire extinguishers were not stored in two kitchen areas as required. Oxygen tanks were not stored properly in seven of 11 patient care areas.

Four employees in the John Cochran dental clinic had not been trained in laser safety before using the devices. Safety needles were not in use at the Jefferson Barracks dental clinic, according to the report.

Inspectors noted problems in the hospitals sedation procedures, where informed consent was not always documented and two patients were allowed to leave unaccompanied after being sedated.

Hospital staff did not always follow up as necessary with mental health patients, including those at high risk of suicide. Records also showed that some patients with traumatic brain injuries did not receive appropriate follow-up care.

The hospitals were also advised to improve their policies on keeping medications safe and preventing contraband from entering.

RimaAnn Nelson, director of the St. Louis VA Health Care System, agreed with the inspectors findings and signed off on an improvement plan that is under way.

The recommendations were administrative and did not impact patient care or patient outcomes, said Marcena Gunter, spokeswoman for the system, in a statement.

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