VA Nursing Home Problems Are Widespread, According to Inspection Reports and Staffing Data

Most veteran nursing homes provided substandard care that may result in actual harm to patients, according to the findings of a new report.

According to a nine month VA nursing home investigation by USA Today, inspection reports indicate that instances of nursing home neglect and abuse occurred at more than half of all facilities inspected, and that there was often a lack of safety protocols to properly monitor and treat patients.

Last year, USA Today and The Boston Globe began an investigation into problems at VA nursing homes throughout the United States, indicating that veteran’s continuously receive substandard care while the VA refuses to release health care inspection reports detailing incident reports and corrective action.

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Unlike private nursing home facilities, which are required to have their quality data and inspections released so they can be compared on a federal website called Nursing Home Compare, VA systems have never released this information, until last month when the U.S. Department of Veterans Affairs (VA) posted inspection data for 101 of its 134 Community Living Centers (CLCs) across the nation.

According to the information released from April through December 2018, 52 of 99 VA nursing homes were found to contain one or more reports of actual harm or jeopardy to veterans across 25 states, the District of Columbia, and Puerto Rico.

Of the 52 cited facilities, inspectors found 11 facilities where veteran safety was in “immediate jeopardy”, 26 facilities where veterans were actually harmed because of inadequate bedsore prevention or treatment, and eight facilities where veterans were actually harmed and in jeopardy.

The inspections included reports of patients suffering from bed sores, veterans moaning in pain from not receiving adequate medication, and veterans being bathed in water temperatures reaching upward of 128 degrees. One facility in Lyons, New Jersey was cited for not having any functional call system for residents to request caregivers.

More than two dozen facilities were found not to have any protocol to ensure bedsores healed or to prevent new sores from developing.

Nursing home bedsores pose a serious health risk for patients, as they can develop into open wounds that can become infected. The injuries most commonly develop in places with prominent bones beneath thin layers of skin, such as the heels, elbows and tailbone. Residents with limited mobility, who have trouble or are unable to move independently, face the greatest risk of the painful and potentially life-threatening pressure ulcers.

VA spokesman Curt Cashour released a statement on March 27, 2019, indicating non-VA nursing homes also have problems, and that by posting the VA reports for the first time, the VA hoped to improve all nursing home care.

According to a VA’s Office of Public and Intergovernmental Affairs statement, inspection reports for the remaining facilities will be released by October 2019. The agency also stated it will continue performing unannounced inspections by an outside agency on a yearly basis that will focus on care of residents and processes used to give that care, how the staff interacts with residents, and the overall nursing home environment.


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