The Northport VA’s four nursing homes had staffing shortages so severe last year that nurses worked as many as 80 hours a week — often on mandatory overtime — and nursing supervisors had to jump in to bathe and feed dozens of patients, an internal investigation shows.
Allegations that the shortages led to the deaths of two patients, overtired nurses and a host of other problems triggered a yearlong investigation by the Veterans Affairs Office of the Inspector General, the department’s independent watchdog.
As of two weeks ago, the Northport VA Medical Center, which includes the nursing homes as well as a hospital and manages a half-dozen community clinics, had 175 vacancies for key personnel such as nurses and doctors, nearly 10 percent of its 1,800-member staff.
The investigation, launched last September, found that Northport’s senior leaders knew about the staffing shortages, mismanaged the nurses to fill the gaps and allowed overtime costs to balloon to $1.5 million in 2017, a nearly $750,000 increase from the year before.
VA officials in Washington also determined that leaders who have since either retired or resigned had pressured nursing home managers to accept new patients when there weren’t enough nurses to properly care for everyone.
The inspectors, however, stopped short of attributing any patient death or serious injury to staffing shortages, citing what they described in their 37-page report as the “many variables” that go into high-quality patient care.
In an addendum to the report, Northport’s interim director, Dr. Cathy Cruise, said she agreed with the findings and would address the staffing shortages.
“Thank you for the opportunity to review our processes to ensure that we continue to provide exceptional care for our Veterans,” Cruise, who has been on the job since mid-July, told investigators in her response.
In the past decade, the inspector general’s office has sent investigators to Northport a handful of times to investigate specific complaints, many tied to aging infrastructure, dirty conditions and management turnover. In the past 18 months, Northport has had four medical center directors, three chiefs of staff and three nursing department directors. All the positions also have a role in overseeing the nursing homes.
Already this year, the 91-year-old medical center had to shut down all five of its operating rooms to repair the air conditioning and the medical center director resigned in July after only a year on the job. And in a 2017 anonymous survey released in April, employees reported broken medical equipment, understaffing, filthy conditions and unresponsive management.
The watchdog’s latest findings come as Senate Minority Leader Chuck Schumer (D-N.Y.) is pushing the VA to put Northport at the top of its list when it starts handing out hiring funds included in its new $86.5 billion budget.
Earlier this month, at the Elmont American Legion Post, Schumer called on the VA to place Northport “at the front of the line” because Long Island has roughly 130,000 veterans, one of the highest concentrations in the nation. Northport, the only VA medical center in the 120 miles between Montauk and Manhattan, cares for upward of 30,000 patients a year.
Overtime and hiring
Investigators put much of the responsibility for the staffing shortages on senior leaders at the time, notably the directors of the medical center and the nursing department. Both are now retired.
“Federal employees are expected to be good stewards of government resources,” the report said. “The OIG found a mismanagement of … senior leaders.”
The two officials, the report said, not only knew about their stretched staff but perpetuated the shortages by not quickly filling vacancies or failing to consider other staffing options such as part-time employees, nurses from a temporary employment agency or a reduction in nursing home residents, the report said.
The medical center director, for example, failed to act on plans by nurse managers that would have complied with recommended staffing levels at each of the four nursing homes, the report said.
In another instance, the report said, the nursing department director changed a staffing algorithm that reduced the number of nurses that experts determined were needed to properly care for patients. Staffing records for 75 randomly chosen days in 2015, 2016 and 2017 showed the nursing homes routinely operated with less than two-thirds the recommended number of employees.
To cover the gaps in staffing, the report said, officials turned to overtime. The nursing department director, at first, directed that she had to authorize overtime. Within weeks, the report said, her directions changed and officials much lower in rank had approval power.
In addition, the report said, the Northport medical center didn’t have accounting measures that allow nursing managers to track each nurse’s overtime day to day so they didn’t know the number of hours until after it had been worked. Data showed the top 2 percent of overtime payouts went to nurses who worked more than 80 hours of overtime within a two-week pay period. The VA defines excessive overtime as 40 or more hours within two weeks.
The extra hours racked up, numbers in the report showed. From fiscal 2016 to fiscal 2017, overtime costs rose from $730,953 to $1.5 million — nearly a third of the medical center’s total overtime spending of $4.7 million, more than twice the $2 million overtime budget. Northport, the report said, spent more on overtime than it would have if it had filled its vacancies.
Northport’s hiring procedures made it difficult to fill vacancies, the report said. The nursing department had the automatic authority to fill positions but slowed the process primarily by seeking out job candidates with qualifications far higher than the VA’s minimum standard and by delaying start dates for months, which led many applicants to take other jobs.
The medical center preferred to hire applicants who had a bachelor of science degree in nursing and five to seven years of experience, though the VA only requires registered nurses to have an associate degree and no experience. A registered nurse and a nursing assistant were hired in January 2017 but took jobs elsewhere after they received start dates in July 2017.
When Scott Guermonprez came on as medical center director in June 2017, the report said, he began putting measures in place to address the staff shortages, such as speeding the hiring process and creating a pool of “intermittent staff.” Guermonprez resigned two months ago after a year on the job.
Two nursing home deaths
Whistleblowers on Northport’s staff alleged the nursing department’s practice of filling vacancies with nursing supervisors and nurses on overtime put nursing home residents at greater risk of “adverse events,” the report said.
Their allegations involved two deaths, both in 2017. Investigators did not name the men.
Early in the year, the report said, one man apparently choked at dinner in the dining hall while nurses attended other residents. The man was found slumped over the table.
Months later, a man died from complications from a fall he took during an overtime shift for a nursing assistant. The employee, investigators found, had already worked 14 hours that day and had pulled 16-hour shifts in each of the five previous days.
While investigators could not determine whether staff shortages precipitated the deaths, the report pointed out that health care experts typically warn that too few nurses on a shift and nurses working too many overtime hours in a workweek lead to more incidents that put patients at risk.
Understaffed shifts in particular have a higher rate that medical literature cited in the report describes as “nurse-sensitive outcomes” such as surgical infections, bed sores, pneumonia or potentially fatal blood clotting.
Nursing home managers determine whether they have enough nurses to adequately care for patients, including new admissions. They then decide whether to accept admissions, although their decision can be overruled by top leaders, the report said, citing VA policy.
Managers, however, told investigators that top leaders ignored their staffing numbers and pressured them to accept new admissions.
As an example, a manager described an admission that the nursing home had to accept when staffing was at less than 75 percent. The manager told the chief of staff that there weren’t enough nurses to handle a new patient with “multiple medical needs.” The chief of staff told the manager to accept the admission anyway, the report said.
“The staff felt distress by the admission of this high acuity resident as it impacted staff’s time with another resident on the unit for end-of-life care,” the report said.
Another time, the report said, a manager felt pressured to take an admission on a weekend even though the new resident had both physical and psychiatric needs and there was a shortage of both nurses and doctors. The manager said the patient required round-the-clock observation for his safety and stayed for months in an area that wasn’t suited to his needs.
The pressure to accept new patients ended in when a new management team took control in August 2017, the report said.
Investigators also looked into allegations that the nursing homes had been closed temporarily to admissions because of staffing shortages and that residents had been transferred to acute-care inpatient units because of shortages. The office substantiated the temporary closing during a review of staffing levels but determined no residents had been moved.
The inspectors made three recommendations: a full review of nursing home staffing to make sure the medical center has enough nurses to care for patients properly; a steady effort to fill nursing vacancies on the nursing home staff and an awareness to use other staffing options to fill the gaps; and better management of overtime to “ensure quality of care and responsible use of financial resources.”
In an addendum to the report, Northport’s interim director Cruise told the inspector general’s office that she and her administration are working to fix the problems.
Nursing leaders, Cruise said, are analyzing nurse-patient ratios every day for each unit.
“Variables that impact the need for nursing staff include severity of patient condition, complexity of care, nursing skill level, skill mix of staff, and actual or projected change in census,” Cruise wrote.
As for hiring, Cruise said, the medical center has authorized filling all vacancies and using more than a half-dozen strategies — from increasing the number of floating nurses to flexible schedule to cross-training — to end the shortages.
As of Friday, the nursing homes had 29 full-time registered nurses and leaders are in the process of hiring two more, said Northport spokesman Levi Spellman. With the new hires, he said, the nursing homes will have the 31 registered nurses called for by VA staffing methodology but still has openings for licensed practical nurses and nursing assistants.
Lastly, Cruise said the medical center has established a task force to decrease overtime and is requiring all overtime to be approved by either a nurse manager or the nurse officer of the day. Administrators, she said, now also have the ability to review overtime in real time and by employee name.
Since the investigation, Spellman said, overtime for the nursing staff at the nursing homes has decreased by 41 percent.
- Leaders covered the staff shortages by using floating nurses and nurses working voluntary and mandatory overtime.
- Nursing supervisors had to feed and bathe nursing home residents.
- Leaders pressured nursing home managers to take new patients when staffing was inadequate, putting all residents at risk.
- The nursing homes had been closed temporarily to admissions because of staffing shortages and residents had been transferred to acute-care inpatient units because of shortages.
- Review nursing home staffing to ensure Northport has enough full-time nurses to properly care for patients.
- Recruit and hire nurses to fill nursing home vacancies and to use until adequate staffing is reached and to use staffing options to ensure patients get proper care.
- Improve management of overtime practices to ensure high-quality care and responsible spending.