Brown Pushes VA to Ensure All Patient Safety Guidelines Are Followed After Independent Report on Chillicothe Death

Inspector General Report Found Secured Windows Could Have Prevented VA Patient Death at Chillicothe VA

WASHINGTON, D.C.  – U.S. Senator Sherrod Brown (D-OH) is calling on the Department of Veterans Affairs to ensure all patient safety guidelines are being followed across the VA, after an independent Inspector General investigation found that secured windows could have prevented the death of a patient at the Chillicothe Veterans Affairs Medical Center. Chillicothe VA has already made changes to adhere to the recommendations in the report. But Brown wants to ensure proper safety protocol is being followed throughout the entire VA.  

In a letter to the Secretary of Veterans Affairs, Robert Wilkie, Brown joined Sen. John Tester (D-MT) in calling on the Secretary to ensure that the report’s recommendations are applied throughout VA’s health care system to protect patients. The VA Office of Inspector General (OIG) conducted the inspection at Brown and Tester’s request.

“The VA must do everything it can to protect patients and save lives,” Brown said.

In the letter, Brown requests that Sec. Wilkie work with all VA facilities to ensure adherence to the Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines for windows in patient care areas. Brown also asked to be notified as recommendations in the healthcare inspection are completed.

Brown’s letter can be found here and below.

September 13, 2018

The Honorable Robert Wilkie

Secretary of Veterans Affairs

810 Vermont Avenue, NW

Washington, DC 20420

Mr. Secretary:

Today’s release of the Office of the Inspector General’s Healthcare Inspection of Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, points to potentially larger patient safety concerns throughout the VA health care system rather than concerns unique to  Chillicothe.  We therefore request that VA ensure that guidelines developed for safety in patient care areas and adherence to Special Observation policies put in place for vulnerable veterans are followed throughout the system.

The Chillicothe Healthcare Inspection shows deficiencies in the hospital’s adherence to the Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines for windows in patient care areas.  The Inspection showed that windows in patient care areas opened wider than six inches as directed in the guidelines.  While we understand that Chillicothe is moving to address this particular safety issue, we are concerned that other VA facilities may also not be adhering to the guidelines.  Therefore we request that you ensure that all VA facilities are following these guidelines and any others that affect safety in patient care areas.  We believe that the incident described in the Inspection was avoidable and thus should be rectified before similar incidents occur elsewhere.

Further, the Inspection notes concerns with adherence to Special Observation policies.  The incident described indicates that the veteran was able to lock a bathroom door thus putting more space between the patient and an assigned observer.  This allowed the patient to access a window while the observer unlocked the door.  This, again, was avoidable and VA should ensure that when patients are under a Special Observation order that their patient care area is in compliance with an observer being within arm’s reach of the veteran.  We understand that Chillicothe has developed a process to address Special Observation orders.  However, we request that VA ensure that facilities, at a minimum, follow a nationally-developed policy on Special Observation orders and ensure that appropriate training and compliance are in place to make certain that all VA facilities are ensuring that the safety of these vulnerable veterans is properly addressed.

Finally, we request that we be notified as Recommendations in the Healthcare Inspection are completed.

We appreciate your attention to this request and look forward to your response.

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