Audit Criticizes Louisiana Veterans Homes

An audit conducted by the Louisiana Legislative Auditor's office found the Department of Veterans Affairs didn't properly address deficiencies at its five vetrans homes including the one in Bossier City (which was cited for 6 different violations).

According to the report, the Bossier City home was cited for these issues:

• Facility failed to ensure all residents were free from physical restraints for 12 residents and that three were free from chemical restraints.
  • Example: Chemical restraints were administered to residents with no indication of staff intervention in an attempt to de-escalate the behaviors prior to the chemical restraint being administered.
• Facility failed to provide services in accordance with each resident’s plan of care for seven of 24 sampled residents.
  • Example: Residents’ care plan included a mitt instead of wrist restraint, but reduction was not enacted upon quarterly review even though resident was a good candidate. No evidence staff had attempted to reduce restraints per the resident’s written plan of care.
• Facility failed to ensure the care plans were reviewed and/or revised for six of 24 sampled residents identified as high-risk for falls and adequate supervision and assistive devices to prevent accidents.
  • Example: Resident admitted to facility and later identified as a high-risk for falls. Resident fell seven times with no revision or review of care plan to induce interventions to prevent re occurrence. Separate resident later fell and sustained hip fracture, with no revision to care plan or preventative measures implemented as a result of two falls four to six days prior.
• Facility failed to ensure that six of the 24 sample residents received adequate supervision and assistive devices to prevent re-occurring falls.
  • Example: Resident assessed and identified as high-risk and placed on Falling Leaf Program. Care plan was not revised and/or reviewed after two falls obtained while attempting to self-transfer from wheelchair.
• Facility failed to ensure medication was administered in safe manner according physician’s order.
  • Example: Resident’s medication was discontinued on 4/10/14 per physician’s order. Medication was not pulled from resident’s medication basket according to facility protocol after discontinuation until review on 4/23/14.
• Failure to ensure accurate vision assessments for residents. Assessment records did not indicate corrective eye wear for residents even though care plan indicates impaired vision.
  • Example: Six residents with impaired vision did not have corrective lenses.

Also, the audit says staff at the homes didn't correct problems found in their internal quality assurance reviews. It also states that Veteran homes spent $7.7 million on health services during a three-year period, but never asked to see data to track contractors' work.

You can read the full report here.