Clarksburg VA Medical Center concludes safety stand down following patient murders

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CLARKSBURG, W.Va. — The Louis A. Johnson VA Medical Center (VAMC) reopened its 3A general medical/surgical unit Tuesday, ending a month-long safety stand down centered on patient safety and care, officials announced.

During the closure, the Clarksburg VAMC did not accept new patients on the medical/surgical unit.

Reta Mays

The move was initiated in response to an Administrative Investigation Board report focusing on patient safety issues and culture at the medical center. The safety stand down came after the guilty plea of former nursing assistant Reta Mays who was charged with second degree murder in the deaths of seven people and assault with the intent to commit murder of an eighth person between 2017 and 2018.

“The Clarksburg VAMC has worked to ensure a top-notch environment of care for North Central West Virginia Veterans,” said Acting Medical Center Director Barbara Forsha. “During the past month, we have conducted extensive education and training on patient safety and care; 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.”

During the safety stand down, the Clarksburg VAMC implemented specific measures to improve patient care to include:

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.

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