VHH could not provide documentation to prove that nurses performed intentional rounding on all veterans during the audit period. Specifically, 32 out of our sample of 35 (91%) veterans did not have complete intentional rounding logs. The 32 veterans accounted for 384 out of 562 (68.3%) intentional rounding logs that had gaps, indicating that rounding did not occur as required. Below is a chart showing the number of intentional rounding logs that had gaps. Each log accounts for one month of intentional rounding.
If intentional rounding is not being completed, then it could increase the risk of veterans having falls or other issues that could adversely contribute to veteran safety and well-being. As already noted (see the “Intentional Rounding” section), intentional rounding reduces falls by an estimated 36%. It is reasonable to conclude that the absence of intentional rounding, as shown here, increased the risk—and likely the number of injuries—while reducing the quality of care, for veterans at VHH.
Authoritative Guidance
According to Section VI of VHH’s NSG-113 Intentional Rounding Policy,
VI. Procedure . . .
- Hourly rounding will occur
- Every hour on every Veteran between the hours of 0600 and 2200
- And reduced to every 2 hours between the hours of 2200-0600 to facilitate sleep.
- Hourly rounding is decreased at night to facilitate sleep for the Veteran. If the Veteran is sleeping, continue to observe and perform detailed rounding when Veteran awakens and/or is aroused for Veteran care activities. Nursing care should be clustered to facilitate Veteran’s sleep.
- Veteran rounding may need to be increased depending on the condition of the Veteran. . .
- Documentation
- Intentional rounds are to be documented at the time they occur by the person completing them.
Reasons for Issue
VHH stated the reason Intentional Rounding Logs were incomplete was either because staff members performed the scheduled room check and forgot to complete the Intentional Rounding Log, or that staff members did not perform those room checks as scheduled. In addition, VHH did not have established monitoring controls to ensure that intentional rounding logs were completed and reviewed.
Recommendations
- VHH should ensure that timely intentional rounding is performed and documented on Intentional Rounding Logs.
- VHH should establish monitoring controls to ensure that Intentional Rounding Logs are completed and maintained.
Auditee’s Response
At present, the Massachusetts Veteran Home at Holyoke (HLY) has a robust intentional rounding program. HLY and [the Executive Office of Veterans Services (EOVS)] implemented nursing policies which postdated the audit period and include the intentional rounding program. These policies state that each Veteran gets rounded on by a licensed nurse or a Certified Nursing Assistant (CNA) 20 times a day (hourly from 6:00am to 10:00pm and every 2 hours from 10:00pm to 6:00am). The HLY nursing leadership continues to review and support improvement of the intentional rounding program documentation. To address this, a process of re-education for all the clinical staff was accomplished in May 2025 during the annual staff education program. The nursing leadership team also established audits of the intentional rounding program starting in April of 2025. To date, 1,919 audits have been completed with real time follow-ups and education being done on audits that do not meet the policy standards. HLY’s senior CNAs have emphasized rounding and documentation with all CNAs.
Auditor’s Reply
Based on its response, VHH is taking measures to address our concerns regarding this matter. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | January 14, 2026 |
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