NOT THE SHARPEST KNIFE IN THE DRAWER: Brain Dead
For more than two years, a nurse at Hefner VA Medical Center in Salisbury, NC, who was supposed to be monitoring frail veterans residing in private nursing homes didn't visit them. Though some had lost "significant" amounts of weight, her notes listed all of them as stable — including one who had died 12 days earlier, according to a federal inspection report issued in September by the VA Office of Inspector General. The nurse was suspended, and subsequently reassigned to a position that does not entail nursing home visits. Donald Moore, the hospital's director at the time, told The Charlotte Observer, "It was poor charting. It wasn't as bad as it seems, though I know that sounds crazy. The feedback on her [from physicians] was very positive. We had over 1,700 employees, and somebody will drop the ball." [Hat tip: OpinionJournal]
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