Care and
Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson
VA Medical Center in Clarksburg, West Virginia 05/10/2021 08:00 PM EDT The VA Office of
Inspector General’s (OIG) Office of Investigations was contacted by the
Facility Director in June 2018 who reported concerns related to the suspicious deaths of nine
patients from profound hypoglycemia (low blood sugar). A criminal
investigation was initiated. The OIG Office of Healthcare Inspections
immediately commenced a parallel healthcare inspection. Healthcare inspectors
finalized their evaluation after OIG investigators completed the criminal
case. On July 14, 2020, Reta Mays, a former nursing assistant, pled guilty to seven counts of second
degree murder and one count of assault with the intent to commit murder by
deliberately administering insulin to eight patients. The OIG found
that the facility had serious clinical and administrative failures, including
hiring and medication security practices, communication of clinical
information, and patient safety deficiencies that contributed to Ms. Mays’s
criminal actions not being identified and stopped earlier. The OIG made three
recommendations to the Under Secretary for Health related to adjudicator
follow-up of unreturned background investigation documentation, rescue
medication security and management, and mortality data analyses. Two
recommendations were made to the Veterans Integrated Service Network Director
to conduct management reviews of the care of patients discussed in this
report and a broader evaluation of patients who may have been harmed in other
ways by Ms. Mays’s actions. Ten recommendations were made to the Facility
Director related to the Pharmacy Service’s inventory accountability,
endocrinology consults, clinical communication expectations, clinical
documentation reviews, clinical care-related reporting expectations, patient
safety event training, interdisciplinary mortality workgroup activities,
oversight and reporting, and a culture of safety. This service is provided to you at no
charge by Veterans Affairs Office of Inspector General
(OIG). |
Tuesday, May 11, 2021
Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia 05/10/2021
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