VA Inspector General Finds Care Deficiencies Contributed to Batavia Resident Death
VA Inspector General Finds Care Deficiencies Contributed to Batavia Resident Death

VA Inspector General Finds Care Deficiencies Contributed to Batavia Resident Death

News summary

A VA Office of Inspector General report has found that deficiencies in care at the Batavia VA Community Living Center contributed to the preventable decline and death of a resident with dementia, anxiety, and diabetes. The resident, admitted to the Buffalo VA Medical Center before transfer to Batavia, experienced mismanagement of dementia and diabetes, including unsafe medication practices and failure to report dangerously high blood sugar levels to physicians. The patient fell on their first night at Batavia, and over a month-long stay, staff inadequately documented medication administration and nutritional intake while repeatedly administering injectable antipsychotic medications. Elevated blood sugar readings, exceeding normal levels by more than six times, were not promptly addressed, leading to the patient’s transfer back to Buffalo VA for hospice care, where they died shortly after. The report also highlighted broader systemic issues such as staffing shortages, unclear nurse education roles, and leadership failures, prompting ten recommendations to improve care quality and prevent similar occurrences. The VA Western New York Healthcare System has begun corrective actions, including leadership changes and collaboration with the Batavia Community Living Center to implement the Inspector General’s recommendations.

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