VA Facility and Environment Reports

PSRS receives reports from a variety of VA employees on several safety issue concerns.

This issue of FEEDBACK presents reports relating to VA facilities: HIPAA concerns occurring outside of direct patient areas, un-staffed locations in medical centers, concerns regarding new construction, elevator safety.

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The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of health information. An estimated 7500 people are expected to file complaints of non-compliance with the Office of Civil Rights during fiscal year 2005.

Two reporters were concerned about protecting patient confidentiality. The first situation was a conversation.

• “While in the hallway I overheard one nurse speaking to another nurse about medical information found in a patient record.”

The second situation was about written documentation.

• “I observed patient's information in garbage can... I have personally removed and shredded such documentation myself on many occasions... The shredder is only a few feet away.”

Three reporters described events occurring in un-staffed locations. The first instance required a quick response.

• “Two employees discovered a patient in the basement corridor in the process of attempting suicide... One employee stayed with patient, keeping him calm, while the other went to get help. When assistance arrived, [the patient was] taken to ER.”
  
  
• “The hospital is now re-looking at access issues.”

The second report detailed an ongoing situation.

• “More than once, ward staff have returned from the weekend to find that ward had been occupied, evidenced by unflushed toilets, food wrappers and dirty linen. Night tour nurses have called police more than once when people were sleeping there. The doors do not lock; the whole wing is vacant.”

The third situation focused on an area closed on weekends.

• “The door is locked to the main elevators. Access is also available on the side elevators and these are supposed to not go to the floor when the unit is closed. On Sunday [employees] were able to come to the unit using the front elevator using their key to unlock it. A patient mistakenly came to the unit... using the side elevators. Other staff has said they have been able to come to the unit, on off hours, using elevators. This allows unauthorized personnel access to computers, charts and equipment.”

A reporter described concerns about un-staffed overnight accommodations.

• “On many occasions we are called to have 'lodgers only' veterans sleep in our area due to lack of beds in the hospital. Veterans are lodger-only status when they traveled long distances, missed appointments, buses, etc. Lodgers are not entered in the computer until after surgery. (I've always wondered what would happen in a fire?)”

The same reporter had followed-up on a report of a person staying in an un-staffed area "all alone, incontinent with no food."

• “He was not incontinent but the odor [came from] what I recognized as oral cancer. He had surgery on the jaw, which was disfigured... Patient wrote that he came from [another] VA sent by a doctor to have the tumor removed and a feeding tube placed in his stomach.”

The patient was taken to the ER by wheelchair. The reporter listed some possible alternatives:

• “Secure area of lodging.”
  
  
• “Have lodgers entered in computer so we have an accurate number and location of every patient.”
  
  
• “Have the hotel idea put into practice.”
  
  
• “Remove lodger program completely and have all patients admitted.”
  
  
• “Give people who missed their appointments bus vouchers to their home or to the hotel.”

Standards have been set by national organizations, such as JCAHO and OSHA, which outline requirements around hospital construction and environmental health. The following report describes issues around a recent event in which employees and patients were affected by construction occurring within their facility.

• “The construction crew was water proofing the building with epoxy-based material... There were strong fumes in the hallway [which] permeated our work space.”

People in the area were affected:

• “Many patients and RN's had headaches and facial numbness,”
  
  
• “Others staggered and felt drunk,”
  
  
• “Employees from other areas of the hospital called the ER to find out why patients were entering their clinics so ill.”

The reporter was unable to identify the causative chemical.

• “[We were] told that construction workers do not have to warn you of hazardous substances they will be using, but do need to provide employees with an MSDS [Material Safety Data Sheet] sheet when requested. None of the hazardous products used during this event had MSDS sheets attached or available upon staff's request from the crew boss.”

Demolition of a clinical area had some unexpected issues:

• “Appropriate and effective infection control barriers were not used during this demolition, resulting in dust and particulate contamination [which] rendered the area unusable during that time... Infection control was not contacted until very late in the process.”

The same reporter noted internal communication problems.

• “Numerous individuals were involved in the process of evaluation, abatement and decontamination... There were informal communications, but no formalized structure to assure that all the issues had been evaluated and addressed.”

A reporter described a potentially hazardous building situation.

• “Over the past two years, our elevators have not worked properly. The elevators do not stop level with the floors very often. This is very unsafe for patients in wheelchairs and those unsteady on their feet. This also causes discomfort for patients, as they have to bump up or down to move from the elevator to the floor if they are being moved on a stretcher or wheelchair.”

The reporter noted other problems about the elevators.

• “Many people have been caught on these elevators when the doors won't open and very often the elevators don't stop on the floor the rider has chosen. Also, the elevators tend to bounce as they are stopping, before the doors open. These unsafe elevators are anxiety-provoking for both patients and staff.”

One recent incident stood out in the reporter's mind.

• “Not long ago, one of my colleagues was caught between floors on the elevator with a patient who was actively bleeding from an artery… Fortunately, the patient had a positive outcome.”