Healthcare Inspection Alleged Inappropriate Care in the Community Living Center Tomah VA Medical Center Tomah, Wisconsin
Report Number 09-00410-174, 7/23/2009
"The purpose of this inspection was to determine the validity of allegations that a registered nurse at the Tomah VA Medical Center, Tomah, Wisconsin, provided inappropriate care during an incident involving a terminally ill patient in the Community Living Center. We did not substantiate that an intentional unsafe act occurred or that the patient died as a result of the incident. We determined that managers did not follow Veterans Health Administration or medical center policy related to allegations of patient abuse. We recommended that managers ensure staff immediately report suspected incidents of patient abuse and that further actions are taken, in accordance with VHA and medical center policy."
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