Lack of Documented Nurse Competency Could Put VA Patients at Risk

by U.S. Medicine

June 7, 2012

By Stephen Spotswood

WASHINGTON — Gaps in VA’s nurse-competency practices might be putting patients at risk, according to an investigation by VA’s Office of the Inspector General (OIG). The report found that nurses went years without being assessed for their proficiency on equipment, and, many times, when they failed to demonstrate competency, VA hospitals took no action.


A dialysis unit at VA Healthcare Upstate New York, VISN 2. Making sure nurses are trained on equipment has been a local issue. Photo from VISN 2 website.

Using data from a Combined Assessment Program (CAP) review conducted between April 2011 and September 2011, OIG investigators analyzed how VA hospitals assess the competency of their registered nurses (RN), how they define competency and how they respond when nurses fail to meet one of the requirements.

This most recent review builds upon previous reports on VA RN competency. A review in 2009 found that 24% of facilities evaluated did not meet Joint Commission competency requirements and lacked documentation of annual assessment and validation of registered nurse (RN) RN competencies.

A healthcare inspection found that nursing staff were not competent in the use of telemetry-monitoring equipment to ensure that correct patient parameters were set and that alarms would sound to alert staff to problems. Another inspection found that lack of RN competency on a cardiac-monitoring unit was known by hospital managers, who had no system in place to correct the problem.

Another review in 2010 found that, of 168 RN competency records reviewed, 19% did not have evidence of competency evaluation. Other reviews identified RN competency issues in dialysis, mental healthcare, long-term care, spinal-cord injury, endoscopy-procedure areas, the operating room and the cardiac-catheterization laboratory.

This most recent review found VA facilities still out of compliance with RN competency-assessment guidelines.

RNs are required to be assessed and validated at least every three years or more frequently, if required by local law or policy. Although all of the VA facilities investigated had policies in place for RN assessment, it was not always clear who had the responsibility to conduct the assessments on a timely basis. Also, methods and documentation requirements were not always addressed.

Lack of Documented Nurse Competency Could Put VA Patients at Risk

Some of the Joint Commission elements of performance can be fulfilled very simply — keeping documentation that includes the dates of assessments, the methods used to determine competency, the signatures of those performing assessments and the signature of the employee assessed.

On both core-competency validation forms and in unit-specific validation forms, however, at least 20% of the time one or more of those items was missing, the OIG report shows. Overall, RN competency documentation was not complete at 15 of 29 facilities.

The biggest— or at least the most serious — problem is the lack of action by facilities when RNs do not demonstrate competency in a skill, according to the report. The Joint Commission requires that hospitals take action when competency expectations are not met. In the report, investigators looked at 349 RNs and found that 58 had been recorded as not meeting competency in a skill. Of those, 41% (24 nurses) were not required to take any action to address that deficiency.

When presented with the report, VA officials concurred with all of the OIG’s findings. According to Under Secretary for Health Robert Petzel, MD, VA has developed a VA Nursing Handbook now in the approval and distribution process. The handbook establishes specific RN competency assessment requirements designed to ensure consistency among facilities. The handbook is expected to be fully distributed by the end of 2012.

VA officials said the agency will require verification of competency-validation documentation through an annual RN Competency Validation Report to be submitted by Veterans Integrated Service Network (VISN) for evaluation by the Office of Nursing Services (ONS).

The ONS also will develop a standardized competency-assessment tool for use during random reviews of facilities.

VA officials noted that local policy will continue to dictate actions to be taken when validation of competencies is not met. The VA Central Office will send a memorandum to VISNs, however, requesting the development of local policy that establishes appropriate action to be taken at the facility when that happens.

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