Chronic staff shortages at the San Francisco Department of Veterans Affairs nursing home led to less care and cleaning for patients, reliance on less qualified contracted staff and "staff too busy to wash their hands," which may have contributed to outbreaks of disease, a new watchdog report says.
The VA Office of the Inspect General (OIG) investigated the facility after allegations of patients at risk because of a lack of nursing and other staff at the nursing home for years. San Francisco VA leaders said many of those issues have now been addressed following the OIG's review.
The review found that leaders of the community living center knew about the nurse shortages, but "continued to accept resident admissions." The nursing home already had to reduce its number of beds because of staff shortages dating back as far as 10 years ago, OIG found.
The Veterans Health Administration -- the arm of VA that includes hospitals, community living centers, clinics and more -- has policies governing the number of nursing staff needed to provide safe and effective patient care, based on how many nursing hours per day are needed. But at the San Francisco nursing home, the employee in charge of staff numbers "had insufficient knowledge" of that policy and assigned hours that were lower than VA's standards, leading the nursing home to underestimate how short-staffed it was.
Nursing assistant vacancies caused by high cost of living, low pay and other issues also led to less staff even when the facility tried to hire more -- a problem that has consistently plagued VA facilities across the country and led to tens of thousands of vacant jobs across the department.
The nursing home had a contract with an agency to provide nursing assistants, but that contractor didn't consistently supply the number VA asked for. Those contracted staff weren't provided the cards needed to access patient health records, and so couldn't record patient care information and there were often vacancies in the role responsible for monitoring the contract, the report said.
Investigators found that nursing home staff were not consistently meeting VA goals for handwashing and leaders didn't consistently monitor it.
Staff told investigators a lack of proper handwashing was caused by the staff shortages -- they were "too busy to wash their hands" and hand sanitizer dispensers were "frequently empty or broken."
In at least six instances between Jan 2018 and September 2019, one or both floors of the nursing home were closed to new patients and visitors "due to infectious disease." In interviews with investigators, managers said that lack of handwashing and enough cleaning staff "may have contributed to the number and length of outbreaks.
The nursing home maintained a high number of residents (more than 90% full) as leaders "struggled to meet the staffing targets," according to the report. More than 10 years ago, nursing home leaders decided internally, without higher approval, to reduce the number of patients admitted because of staff shortages.
Investigators found two incidents of "wandering and missing" veteran patients and five who fell but could not definitively link those to the staffing shortages. One of those was found shortly after going missing in a nearby cafeteria. The other was found hours later, miles from the center.
Staff tried to relocate the veterans to secure community living centers but were unable to find one to transfer them to, so they moved the patients to a floor of the nursing home with limited exits and monitored them. Since then, neither has gone missing, according to the report. When staff reported the incidents of missing patients or those who fell, they did not cite staff shortages as a reason, and investigators could not find evidence that lack of staff caused the incidents.
The nursing home did not have a 24-hour cleaning staff assigned consistently, according to the report, but cleaning services were available as needed. Staff said they didn't know how to contact the cleaning staff during off-hours or said they did not answer calls.
Investigators who visited the center said it was "not dirty" but there were flying insects, which leaders blamed on food in patient's rooms, open doors and windows. Bug lights were ordered but never set up because it wasn't clear who was responsible for maintaining them. Staff were supposed to inspect areas for insects monthly but didn't until earlier this year.
High turnover in leadership also contributed to issues at the nursing home, investigators found. The center's chief and nurse manager positions saw high turnover or outright vacancy since at least 2017. And while the nursing home struggled with "inconsistent leadership and endured progressive staffing challenges," the nurse executive didn't provide enough oversight, according to the report.
The OIG recommended VA temporarily reduce the number of beds at the nursing home for a more manageable number of patients, review its contract for nursing assistants, retrain staff, improve hiring, ensure cleaning staff is available, address insect issues, ensure staff adheres to handwashing policies and more.
San Francisco VA Healthcare System Director Bonnie Graham said in response to the OIG report that the nursing home cut its vacancy rate for 45% in October 2019 to 9% in August 2020, with an average vacancy rate of about 13% and the center is "meeting staffing needs." The center also reduced the number of patients to 80 based on its number of staff and stopped using the previous contracted staff.
The nursing home expanded its recruitment, hiring 18 full-time nursing assistants and providing incentives to new and current staff, Graham said, and added more cleaning staff. No complaints of flying insects were mentioned by veteran patients in the last six months. The nursing home also now conducts regular unannounced monitoring of staff handwashing, Graham said.
Read the full report:
—
Years later, VA still hasn't set maximum wait times for community care referrals
Texas VA healthcare system went without a gynecologist for nearly 2 years
VA doctor said they did 'not care' if veteran killed himself. 6 days later he did.