Patients at Atlanta's Veterans Affairs hospital didn't get their medications on time because hospital staff lacked access to medication carts that actually worked, the VA's inspector general found.
Of 19 nurses interviewed at the Decatur, Ga., facility during the IG's unannounced April 7 visit, 17 told the IG they failed to give patients their medications on time "because they did not have access to a working medication cart."
That may explain why the IG also reported that his staff "observed medications being administrated late on all the floors."
The IG's revelation about medication issues in Atlanta comes on the heels of a nationwide scandal surrounding the Department of Veterans Affairs over delayed care and patient deaths. The controversy led to the resignation of VA Secretary Eric Shinseki earlier this summer, and Congress is demanding reforms.
The Atlanta facility, which serves 87,000 veterans, has been part of the controversy. Widespread mismanagement there was blamed for at least three preventable patient deaths, and possibly a fourth. The hospital failed to deliver adequate and timely mental health care to veterans prior to the deaths from suicide or drug overdose. Despite that, the head of the Atlanta VA until December 2012, James Clark, collected almost $66,000 in performance bonuses in 2007-11.
In the April inspection, at least some of the medication carts were unusable because their batteries didn't have enough juice.
Four of five carts in one part of the 405-bed facility had to remain plugged in due to "insufficient battery power," the IG found.
Drawers in two of the carts didn't even lock, posing challenges for nurses managing the medicine and creating a security issue.
On two other floors, five of the 14 carts in service had to be constantly plugged in, and six had "unsecurable medication drawers," according to the IG.
Even when the nurses documented the issues with the medicine carts and the late medications, the response from hospital managers was "insufficient," the IG said.
Though leadership at the hospital responded to complaints about the medication-carts issue, VA purchasing and contracting efforts to fix or get new equipment has been "slow" because of a disconnect among the different offices within the Atlanta hospital all involved in the process, the IG found.
Four representatives told the IG that "one or more of the other program offices were not following certain procedures, which impacted their ability to do their work related to the medication cart purchase and repair."