October 1, 2005, - March 31, 2006

The inspection was conducted to determine if Veterans Health Administration (VHA) facilities complied with VA and VHA policies and Federal regulations governing patient transportation, if VHA facilities had effective internal controls to ensure safe patient transportation, and if opportunities existed to improve patient safety by strengthening patient transportation services (PTS) programs. We made nine recommendations to the Under Secretary for Health to ensure defiecinceies and vulnerabilities identifyfied are corrected. To improve and strengthen PTS programs at VHA facilities, we recommended the Under Secretary for Health needed to:

• Improve initial and follow-up screenings of motor vehicle operators, incidental operators, and volunteer drivers.
• Ensure annual safe driving training is provided to all employee and volunteer drivers and publish policy regarding

• include instruction in handling medical

  emergencies.

  • Ensure drivers’ compliance with all aspects of VHA’s employee safety alert regarding transportation in 15-passenger vans.
  • Ensure patient safety is maintained through the consistent practice of securing patient care equipment, other cargo, and vehicles and ensure that security of patients in vehicles is reviewed, policies are established, and observed.
  • Publish policy describing required equipment needed in vehicles used to transport patients.
  • Provide guidance to VA facilities regarding employee escort for patients with special medical or mental health needs and ensure that incidents occurring during trips are reported to appropriate clinical staff and documented in the patients’ medical records.
  • Ensure contracts for transportation services require that vendors certify that their drivers have been screened, trained, and are competent to safely transport VA patients, and that medical centers ensure that initial and follow-up certifications are received and retained.
  • Ensure VA managers consider the use of volunteer drivers in emergency planning.
  • Require that transportation incidents and accidents are reported to VHA Headquarters’ managers and program officials.

  The Under Secretary for Health concurred with the recommendations and provided an action plan with target dates to implement the recommendations. (Healthcare Inspection, Inspection of Veterans Health Administration

  Office of Healthcare InspectionsPatient Transportation Services, 04-00235- 180, 8/4/05)

  Issue: Suspicious Death.

  Conclusion: Patient care did not meet community standards and VA-Defense data-sharing was not effective.

  Impact: Improved quality care and patient safety.

  OIG’s Office of Healthcare Inspections was requested by the Secretary of Veterans Affairs to review the care of an active duty marine who was seriously wounded in Iraq, treated initially in Department of Defense (DoD) facilities, and transferred for rehabilitative care to the James A. Haley VA Medical Center (JAHVAMC), where he died three weeks later. The purpose of this inspection was to review the care of this marine, focusing particularly on his care at the JAHVAMC. In performing this review, it became apparent that many of the issues it raises have implications for the medical care of other combat-wounded soldiers, sailors, marines, and airmen.

  In general, we found the intensity and comprehensiveness of his rehabilitative care to be high. However, we noted signifi cant deficiencies with respect to other specifi c aspects of care. These involved the evaluation of persistent fever and abnormal white blood cell count, and the management of mental status changes at the end of his life. In addition to these issues, an underlying theme that emerged is that many of the JAHVAMC clinical staff simply did not grasp how inherently fragile this patient was. The lack of appreciation of his medically compromised state may have led to less intensive diagnostic evaluation than were indicated. We also found that the JAHVAMC staff failed to ensure that all medical information was obtained from the referring military treatment facility regarding this patient’s medical care and that medical staff required additional training to better manage multiple trauma patients returning from the Gulf for rehabilitation. We made recommendations to improve training for physicians to treat blast injury and other combat-wounded patients, timely and quality clinical consultations, and medical records transfers. Senior VA management concurred with the recommendations and provided acceptable implementation plans. (Healthcare Inspection, Review of Quality of Care, Department of Veterans Affairs James A. Haley Medical Center, Tampa, Fl, 05-00641-149, 6/1/05)

  Patient Transportation Services, 04-00235- 180, 8/4/05)

   

  Issue: Suspicious Death.

  Conclusion: Patient care did not meet community standards and VA-Defense data-sharing was not effective.

  Impact: Improved quality care and patient safety.

  OIG’s Office of Healthcare Inspections

• OIG’s Office of Healthcare Inspections was requested by the Secretary of Veterans Affairs to review the care of an active duty marine who was seriously wounded in Iraq, treated initially in Department of Defense (DoD) facilities, and transferred for rehabilitative care to the James A. Haley VA Medical Center (JAHVAMC), where he died three weeks later. The purpose of this inspection was to review the care of this marine, focusing particularly on his care at the JAHVAMC. In performing this review, it became apparent that many of the issues it raises have implications for the medical care of other combat-wounded soldiers, sailors, marines, and airmen.

  In general, we found the intensity and comprehensiveness of his rehabilitative care to be high. However, we noted signifi cant deficiencies with respect to other specifi c aspects of care. These involved the evaluation of persistent fever and abnormal white blood cell count, and the management of mental status changes at the end of his life. In addition to these issues, an underlying theme that emerged is that many of the JAHVAMC clinical staff simply did not grasp how inherently fragile this patient was. The lack of appreciation of his medically compromised state may have led to less intensive diagnostic evaluation than were indicated. We also found that the JAHVAMC staff failed to ensure that all medical information was obtained

  from the referring military treatment facility regarding this patient’s medical care and that medical staff required additional training to better manage multiple trauma patients returning from the Gulf for rehabilitation. We made recommendations to improve training for physicians to treat blast injury and other combat-wounded patients, timely and quality clinical consultations, and medical records transfers. Senior VA management concurred with the recommendations and provided acceptable implementation plans

  death. The confidential complainant alleged a patient died under what appeared to be questionable circumstances. We substantiated a delay in definitive treatment of the patient. The patient did not undergo defi nitive treatment until 3 hours after admission. VHA treatment standards for myocardial infarction call for definitive treatment to begin within 90 minutes after presentation to a hospital. We substantiated the delay in receiving reperfusion therapy was due to the concurrent care of other patients in the cardiac catheterization lab. Under the circumstances, this patient was treated as soon as possible.

  We concluded it is doubtful the delay was clinically significant due to the length of time the patient experienced symptoms prior to presenting to the emergency room (ER) and the condition of the patient on presentation. We recommended the VISN Director should ensure the medical center has a written contingency plan for patients arriving in the ER with acute coronary syndrome and coronary intervention not being available. The VISN and Medical Center Directors concurred with the recommendation and have taken actions to develop an action plan to implement the recommendation. (Allegation of Substandard Cardiac Catheterization Care, Hunter Holmes McGuire VA Medical Center, Richmond, VA, 05-00198-181, 8/4/05)

  Issue: Failure to treat.

  Conclusion: Clinicians did not exercise good judgment in declining to speak to a patient.

  Impact: Improved patient safety.

  The purpose of the review was to determine the validity of allegations made by an anonymous complainant. We substantiated the allegation that psychiatrists refused to treat a suicidal patient because he was not a mental health patient and that mental health clinic staff did not follow established procedures when the patient called threatening to kill other people and then himself. We could not substantiate a deliberate attempt to "cover up" the incident. However, medical center management failed to exercise due diligence in investigating, reporting, and following up on this case.

  We also found VA police officers failed to follow policy when they elected not to notify local law enforcement of the patient’s situation, the patient’s primary care physician failed to refer the patient for a mental health evaluation despite multiple indications for doing so, and the medical center’s policies on managing urgent consultations were incongruent. The allegation that the patient might not have committed suicide if he received the treatment that he needed was speculative and therefore could not be substantiated or refuted. However, the relevant literature on this subject indicates a timely and knowledgeable assessment of suicide risk and professional intervention by a mental heath expert would have increased the likelihood of a better outcome. We made several recommendations for improvement in mental health care, suicide prevention, and suicide reporting. The VISN and Medical Center Directors agreed with the recommendations and provided acceptable improvement plans.

  VA James A. Haley Medical Center Tampa, FL

  Issue: Delay in definitive treatment.

  Conclusion: Clinicians were not in compliance with VHA treatment standards for myocardial infarction patients.

  Impact: Improved quality care and patient safety.

  We initiated an inspection in response to a complaint alleging lapses in cardiac catheterization care contributed to a patient’s death. The confidential complainant alleged a patient died under what appeared to be questionable circumstances. We substantiated a delay in definitive treatment of the patient. The patient did not undergo defi nitive treatment until 3 hours after admission. VHA treatment standards for myocardial infarction call for definitive treatment to begin within 90 minutes after presentation to a hospital. We substantiated the delay in receiving reperfusion therapy was due to the concurrent care of other patients in the cardiac catheterization lab. Under the circumstances, this patient was treated as soon as possible.

  We concluded it is doubtful the delay was clinically significant due to the length of time the patient experienced symptoms prior to presenting to the emergency room (ER) and the condition of the patient on presentation. We recommended the VISN Director should ensure the medical center has a written contingency plan for patients arriving in the ER with acute coronary syndrome and coronary intervention not being available. The VISN and Medical Center Directors concurred with the recommendation and have taken actions to develop an action plan to implement the recommendation. (Allegation of Substandard Cardiac Catheterization Care, Hunter Holmes McGuire VA Medical Center, Richmond, VA, 05-00198-181, 8/4/05)

  Issue: Appropriateness of Surgical Service management and adequacy of DOD sharing agreement.

  Conclusion: Physician assistant inappropriately served as chief of surgery and more operating room time should improve access to care.

  Impact: Compliance with VHA directives and improved access to care.

  The purpose of the review was to determine the validity of two allegations regarding the surgical service at the Anchorage clinic of the Alaska VA Healthcare System and Regional Office. We substantiated the allegations. For the past 4 years, a physician assistant has served as the Chief of Surgical Service, a

  to that time, a surgeon served in the position. Joint Commission on the Accreditation of Healthcare Organizations standards and VHA directives require all medical staff service chiefs to be board-certifi ed physicians. We recommended a board-certified surgeon be designated as Chief of Surgical Service and the facility director agreed.

  Our review found that the facility’s sharing agreement with Elmendorf Air Force Base has not adequately served VA patients’ surgical needs. While the members of the surgical staff acknowledged problems in the past with obtaining adequate operating room time and supplies needed for the procedures they performed at the joint venture hospital, they stated that the situation was addressed and has improved over the past year. Therefore, we made no recommendations regarding surgery at the joint venture hospital. (Healthcare Inspections, Surgical Service issues, Alaska VA Healthcare System and Regional offi ce, Anchorage, AK, 05-02527-205, 9/20/05)

  Issue: Communication and documentation.

  Conclusion: Medico-legal cases not properly referred, consultations inappropriately canceled, autopsies not requested, and time and attendance documentation needed improvement.

  Impact: Improved quality care and compliance with policy.

  The purpose of the review was to determine whether multiple allegations made by a former employee had merit. ...We did substantiate that cases of potential medico-legal significance were not consistently identified and referred to law enforcement authorities, autopsies were not consistently requested per policy, and medical center staff cancelled consultation requests prior to notifying the patients’ providers. While not an allegation, we noted that subsidiary time and attendance reports were not always completed.

  We recommended that VISN and Medical Center Directors ensure that:

  • Cases of potential medico-legal significance are identified and referred to appropriate law enforcement authorities.
  • Authorized employees document referrals to law enforcement authorities and their ultimate disposition.
  • Providers review the medical records and reschedule cancelled consultations as needed.
  • Appropriate staff receive training on the consultation tracking system.
  • "Subsidiary Time and Attendance Reports—Part Time Physicians" are completed and signed as required.

  Because the medical center had implemented a system to promote autopsy requests, we did not make a recommendation. The VISN and Medical Center Directors agreed with the recommendations and provided acceptable improvement plans. (Healthcare Inspection, Patient Care, Fraud, and Mismanagement Issues, VA Medical Center, San Juan, PR, 04-02962-158, 6/24/05)

  ...

  Quality of Patient Care

  In 1 of 47 Hotline inquiry allegations regarding deficiencies in the quality of patient care, a VHA review determined several pharmacists had stopped checking dose carts. Management immediately reinstated reviewing all doses daily using a checklist, and counseled the supervisor for failure to detect and address the departure from policy.

  In another case, a VHA peer review determined that a physician displayed a significant lack of compassion and kindness, and that the attending nurse did not pursue her concerns about the patient’s discharge when the physician disagreed with her. Management counseled both the physician and the nurse and ordered the emergency room staff to participate in a refresher course on proper patient management and documentation of treatment.

  ...

  Patient Safety

  Among the five allegations of patient safety deficiencies at VA facilities was a complaint resulting in a VHA review determining that a treatment provider failed to identify a patient’s colon cancer and the patient subsequently experienced a 7-week delay in being scheduled for a specialty clinic appointment. Risk Management met with the veteran to discuss the diagnosis and its implications. The review also found other problems in the delivery of health care involving the lack of communication between specialists and clinicians ordering tests. Management took action to resolve the problem.

  

  Veterans Health Administration (VHA)

  A former VHA medical research coordinator pled guilty to criminally negligent homicide, mail fraud, and false statements after an extensive investigation revealed that he falsified medical data that "qualified" veterans to participate in an experimental drug study at a VAMC. As a result of the criminal scheme, at least one veteran died, and the health of countless others was put at substantial risk.

  Two men pled guilty to demanding a bribe from a company in connection with a Government contract administered by a VA consolidated mail outpatient pharmacy (CMOP). The indictment charged that the CMOP director approached the owners of a company and demanded approximately one-third of the company’s ownership and cash receipts derived from a CMOP contract for over $50 million, and threatened to cancel the contract if his demands were refused. The second man charged in this scheme worked at the CMOP on an independent contract basis and, in a series of telephone conversations with company owners, requested paperwork that would enable him to obtain a share in the company.

  The Tennessean, Nashville, TN October 21, 2004

  

   

  Summary of Findings

  Deficiencies identified during prior CAP reviews relating to management of veterans health care programs were discussed in OIG’s

  Summary Report of CAP Reviews at VHA Medical Facilities October 2003 through September 2004, issued March 7, 2005. During this reporting period, OIG identified similar problems at the medical facilities.

   

  • ...A repeat finding is that utilization management programs were inconsistent and needed improvement. In response to the FY 2003 report, VHA released a new directive in March 2005 that will provide improved consistency. Also, facility managers did not consistently benchmark their results or identify specific corrective actions when problems were identified. OIG found that some significant QM actions did not succeed because existing tracking systems did not assure full implementation...

  ...Part-Time Physician Time and Attendance

  • ...VAMC managers did not have effective controls in place to ensure that part-time physicians time and attendance records were accurate at 3 of 16 facilities tested. Physicians did not complete appropriate time and attendance records, and timecards were not posted based on the timekeepers’ actual knowledge of physicians’ attendance. Additionally, timekeepers did not receive annual refresher training, and desk audits were not conducted as required by VA policy....

  ...Employee Surveys

  OIG obtained employee feedback from responses to a web-based survey implemented at 24 CAP reviews. All employees of each facility were notified by e-mail about the survey and were provided with the Web address. OIG received 5,218 responses. Since the earliest CAP reviews, OIG has systematically elicited employees’ perceptions on a wide range of issues. The resulting data can provide an independent, objective indicator of employee satisfaction for facility management to use in decision-making...

  • OIG noted the following deficiencies that were common to most facilities:

  1. Fifty-one percent of the responding employees believed they had not been offered opportunities for career advancement.
  2. More than 34 percent of respondents asserted that work orders for needed repairs were not addressed promptly at their facilities.
  3. Only 40 percent of responding employees felt staffing levels were usually sufficient to provide safe patient care.

  Physical Plant Environment

  OIG conducted environment of care inspections in 24 facilities evaluating primary care and specialty outpatient clinics, inpatient wards, emergency rooms, intensive care/coronary care units, nursing home care units, domiciliary units, psychiatry units, surgery, and rehabilitation areas, as well as in some kitchens, canteens, or supply processing and distribution areas.

  • Twelve of the 24 facilities were generally clean and well maintained with minor issues management corrected immediately during our inspections, and 12 facilities received recommendations to correct deficiencies in the environment of care. Two of these 12 facilities had pervasive unacceptable levels of cleanliness, and safety and infection control deficiencies. One of the two facilities had to divert admissions of immune suppressed patients because of aspergillosis exposure risks to patients. Managers needed to improve procedures to ensure unobstructed hallways, secure chemical storage areas and medications, ensure patient privacy and safety, and strengthen cleaning and sanitation procedures. ..

• Veterans Health Administration

  Misuse of Time by Physicians

  Two administrative investigations substantiated misuse of official VA time by physicians. In one case, a full-time physician worked for another employer during part of his VA tour of duty on 174 days over a period of nearly 3 years. In the second case, a full-time physician, who has since left VA, performed professional services and generated income for a VA-affiliated medical school during his VA duty hours. In both instances, the physician’s supervisor did not ensure the physician followed time and attendance policies. VHA officials agreed to take appropriate administrative action against the physician still employed by VA, and against both supervisors. They also agreed to take corrective action regarding the currently employed physician’s unauthorized absences...

• Quality of Care

  Issue: Medical sanitation and

  part-time physicians’ time and

  attendance.

  Conclusion: Management did

  not maintain appropriate

  levels of cleanliness and

  fully implement time and

  attendance controls.

  Impact: Strengthened controls

  over quality of care and time

  and attendance.

  Our purpose was to review alleged deficiencies in the environment of care, quality of patient care, resident supervision, and physician time and attendance as reported during an April 8, 2004, national television broadcast of Primetime. This report addresses the results of our review of environment of care and time and attendance issues.

  Our review of the quality of patient care, resident supervision, and time and attendance practices specific to the surgeon who was the subject of the Primetime broadcast continues, and the findings will be discussed in a separate report. Although there were opportunities to improve general housekeeping at both divisions, OIG did not find the conditions to be as egregious as cited in the Primetime broadcast. The hemodialysis unit at the Wade Park Division is scheduled to be moved to a new location early in 2005. However, efforts needed to be made to improve conditions in the existing area. Most patients and employees from both divisions indicated high levels of satisfaction with the quality of care and with the facilities’ cleanliness. Medical center managers had not fully implemented time and attendance controls recommended in our February 2004 follow-up report. Although most part-time physicians were on duty as required by their scheduled tours, 4 of the 73 (5 percent) part-time physicians scheduled for duty were not on duty, approved leave, or authorized absence under circumstances similar to those OIG identified during our follow-up report.

   

  Data Validity

  Issue: Compliance with Public Law 107-135.

  Conclusion: VA data reported

  on specialized mental health

  programs for this year, as in

  prior years, remains error-

  prone and lacking in adequate

  support.

  Impact: Accurate data.

  Healthcare Inspections

  

  Issue: Delay in diagnosis and treatment.

  Conclusion: Clinicians did not provide appropriate care for the patient’s serious back lesion.

  Impact: Corrective actions should reduce the possibility of reoccurrence.

  OIG conducted an inspection to determine the validity of allegations regarding the diagnosis and treatment of a back lesion at the VA medical center. The complainant alleged:

  • That he went to the VAMC with a complaint of a back lesion and was provided prescribed antibiotics without examining his back.
  • That the next day he return to the VAMC complaining the lesion had gotten bigger and was told the antibiotics needed time to work.
  • That there were instances of staff inattentiveness and indifference to his needs.

  While the inspection did not substantiate the complainant’s back was not examined, OIG did conclude that, overall, the complainant did not receive appropriate care for a serious back lesion. In addition, there was inadequate documentation of physician supervision of several physician assistants (PAs) who saw the complainant.

  As a result, OIG recommended the VISN and VAMC directors ensure that:

  • Systems managers obtain a peer review of this case and discuss the results of the peer review with the PAs and managing physicians involved in this case.
  • System managers ensure that all PAs and supervising physicians follow Medical Center Policy Memorandum 11-002, and that PAs are being appropriately supervised.
  • System managers address the patient’s concerns regarding his treatment and perceived staff indifference with the patient.
  • The VISN and VAMC directors agreed with the recommendations and provided acceptable implementation plans. (Healthcare Inspection, Alleged Delay in Diagnosis and Treatment, Michael E. DeBakey VAMC, Houston, TX Report 04-00036-42, 11/30/04)

  

  Issue: Patient abuse.

  Conclusion: The patient was not properly monitored.

  Impact: Improved patient

  monitoring and documentation

  of care.

  OIG conducted an inspection to determine the validity of a patient abuse allegation. A community nursing home administrator alleged a resident returned from a VAMC admission with initials carved in his left leg. The review concluded the carvings were made while he was admitted at the VAMC, but was unable to positively determine if they were or were not self-inflicted. OIG recommended the facility:

  • Develop a skin integrity program for psychiatric patients who are mobility impaired.
  • Document activities of daily living for all psychiatric patients.
  • Use this case to reinforce the importance of careful monitoring and documentation of care for psychiatric patients.

  The review also recommended the nursing home obtain blood samples for baseline testing because of potential risks to the patient. The VISN director concurred with the first two fi ndings and recommendations, partially concurred with the third, and provided acceptable improvement plans. (Healthcare Inspection, Alleged Patient

  

  Quality Management

  ...Our inspection of VHA facility quality management programs found facility managers needed to strengthen programs through increased attention to the disclosure of adverse events, utilization management, patientcomplaints program, and medical record documentation reviews. Facility managers needed to strengthendesignated employees’ data analysis skills and clearly state their expectations to all managers, programcoordinators, and committee chairpersons responsible for monitors that corrective actions must be evaluated until resolution is achieved....

The purposes of this review were to determine whether: (1) VHA facilities had comprehensive, effective programs designed to monitor patient care activities and coordinate improvement efforts; and (2) VHA facility senior managers actively supported quality management efforts and appropriately responded to results.

All of the facilities reviewed during 2003 had established comprehensive programs and performed ongoing reviews and analyses of mandatory areas. We noted improvements in several areas compared with our 2002 review. However, facility senior managers need to strengthen programs through increased attention to the disclosure of adverse events, the utilization management program, the patient complaints program, and medical record documentation reviews. Senior managers need to strengthen designated employees’ data analysis skills, benchmarking, and corrective action identification, implementation, and evaluation across all monitors.

Because of continued weaknesses in data management, particularly the implementation and evaluation of corrective actions, facility senior managers need to clearly state their expectations to all managers, program coordinators, and committee chairpersons, who are responsible for quality management monitors, that corrective actions must be evaluated until resolution is achieved. To provide reasonable assurance that its facilities are thoroughly addressing quality of care and patient safety issues, VHA needs a stronger system for corrective action implementation and evaluation. The Acting Under Secretary for Health concurred and provided responsive implementation plans. (Healthcare Inspection, Evaluation of Quality Management in VHA Facilities, Fiscal Year 2003, 03-00312-169, 7/14/04) ...

Issue: Suspicious death. Conclusion: Nursing staff did not ensure patient’s safety or provide acceptable standards of care. Impact: Incident appeared to be isolated.

Return to top

This page was last updated on 10/05/2007 01:02 PM

 editor@VA Malpractice.Info

The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.

In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.

This site contains information on va malpractice, veteran administration medical malpractice and veteran administration medical malpractice attorneys and lawyers. Web site for information on va malpractice claim and va medical malpractice claims as well as veterans administration patient safety issues. Information on medical malpractice at the VA, Veterans Administration medical errors, legal representation for medical errors