CLARKSBURG, W.Va. — The Clarksburg VA Medical Center announced Tuesday that it has reopened the area of the hospital where a former nursing assistant worked and took the lives of seven veterans.
The hospital said a month-long safety stand down has been completed in the 3A general medical/surgical unit at the facility. It said it’s focused the last 30 days on training, procedures and staffing.
The VA originally announced the safety stand down on Christmas Eve following its completion of an internal investigation into the case of former nursing assistant Reta Mays. The results included the replacement of Medical Center Director Dr. Glenn Snider Jr.
Mays, 46, is awaiting sentencing after pleading guilty earlier this year to killing 7 veterans by injecting them with insulin. Her attorneys have asked the judge to delay her sentencing.
The charges and plea followed a two-year investigation that began after several suspicious deaths were reported, possibly as many as 20. Mays had access to the veterans’ hospital rooms. She wasn’t supposed to have access to insulin.
The VA’s response came after an Administrative Investigation Board’s report which focused on patient safety issues and culture at the Clarksburg hospital.
“What happened at the Louis A. Johnson VA Medical Center was unacceptable, and we want to ensure that Veterans and families know we are determined to restore their trust in the facility,” Veterans Health Administration’s Executive in Charge, Dr. Richard Stone said in that Christmas Eve news release. “Transparency and accountability are key principles at VA, and they will guide our efforts in this regard.”
The Clarksburg VAMC said Tuesday that during the past month it’s been able to focus on education and training as it relates to patient safety.
Acting Medical Center Director Barbara Forsha said Tuesday the goal is to “ensure a top-notch environment of care for North Central West Virginia Veterans.” She said during the last month they’ve “implemented new and improved processes for oversight and management of all patient care units; and ensured we have a strong, experienced leadership staff onboard to rebuild trust and improve transparency and accountability.”
Forsha will continue to serve as acting director. There’s a nursing leadership team at the hospital along with an experienced hospitalized, the VA said.
A Tuesday news release from the hospital listed the following items as improvement to patient care that was accomplished during the safety stand down:
Education and Training
Retraining of all Clarksburg VAMC personnel involved in reporting urgent issues throughout the chain of command.
Reviewing of core and unit-specific competencies and performance measures for nurses.
Educating on culture of safety and patient safety.
High Reliability Organization training to maximize safety and minimize harm.
Educating on electronic health record documentation to ensure universality.
Reviewing entire patient admission assessment process.
Procedural Operations
Establishing a Gemba board as a visual management tool visible to all members of a workplace, to track status on the medical/surgical unit.
Consistent rounding by nurses and doctors on all wards, including hourly rounding by nurses and 12-hour rounding by nursing leadership to conduct a physical assessment of each patient.
Implementing Clinical Pathways to guide evidence-based health care.
Staffing
VA Pittsburgh Healthcare System Deputy Director Barbara L. Forsha continuing to serve as the Clarksburg VAMC’s acting medical center director.
Ensuring a detailed nursing leadership team is onsite.
Putting in place an acting inpatient director of hospitalists who is an experienced hospitalist in the community.