Philadelphia, PA
Philadelphia VAMC Fails to Monitor Post Anesthesia Patients, Medical Records Deficiencies & Dentists Who Don't Change Gowns Between Patients-2005 VA OIG Report
Moderate Sedation –
Controls Needed To Be Improved
Conditions Needing Improvement. Clinical managers needed to ensure that patients
who receive moderate sedation1 are appropriately monitored during transport from
procedure areas to the Post-Anesthesia Care Unit (PACU). Additionally, they
needed to ensure that pertinent medical information is documented in patients’
medical records, and that clinicians involved in the care of these patients
maintain proper certification.
Patient Monitoring. Patients who received moderate sedation in the
gastroenterology procedure area were transported to the PACU without continuous
monitoring of their vital signs (blood pressure, pulse, and respirations). While
clinical staff accompanied the patients from the procedure area to the PACU,
Veterans Health Administration (VHA) regulations require that patients who need
transport to a post-procedure recovery area after the administration of
anesthesia, including moderate sedation, have their vital signs continuously
monitored until they arrive in the PACU.
Medical Record Documentation. A review of 10 patients’ medical records showed
that 5 records lacked critical patient information. Documentation deficiencies
included omissions of an American Society of Anesthesiologists (ASA)
classification,2 a consent for anesthesia, an appropriate assessment of a
patient’s elevated blood pressure, and incomplete documentation of two patient
assessments in the PACU. In addition, one of the five records did not document
who would accompany the patient home at the time of discharge. VHA regulations
require that ASA classifications, signed patient consent forms, patient
assessments, and discharge information be documented in the patients’ medical
records.
Certification Requirements. A review of the scopes of practice and training
files for two registered nurses, and the credentialing and privileging files for
two physicians and one dentist, showed that one physician did not have a current
advanced cardiac life support (ACLS) certification. The medical center’s policy
governing moderate sedation requires that employees who administer moderate
sedation or monitor patients during and after sedation have ACLS certification.
Recommended Improvement Action 1. We recommended that the VISN Director ensure
that the Medical Center Director requires that: (a) patients who receive
moderate sedation are appropriately monitored during transport to the PACU,..
1 Moderate sedation is a drug-induced depression of consciousness used to
control pain and discomfort associated with minor surgical procedures and
diagnostic examinations.
2 ASA classification is the assessment of physical status and risk of patients
who require anesthesia.
Combined Personal Protective Equipment. Dental Clinic employees did not have
adequate supplies of surgical gowns, and therefore, were not always able to
change gowns between patients. VHA regulations require that employees be
provided with appropriate personal protective equipment (such as gowns, gloves,
and masks). Processes to ensure adequate supplies of gowns for the clinic were
not in place, which increased the risks of contamination and infection for the
Dental Clinic’s patients and employees. Managers began addressing this condition
while we were on site.
Refrigerator Temperatures. Medication and nourishment refrigerator temperatures
were frequently above or below the range recommended by the medical center's
policy (36 degrees to 38 degrees Fahrenheit). Employees monitored and recorded
refrigerator temperatures daily, but did not generate work orders when
temperatures were outside the acceptable range. Consequently, the refrigerators
were not inspected, repaired, or replaced.
March 23, 2005 VA OIG
Report
The complainant alleged that: (1) His Primary Care Clinic physician inadequatel
examined his diabetic foot wound and did not prescribe oral or topical antibiotics on
July 9, 2002; and (2) Podiatry Clinic clinicians did not evaluate his medical condition
when he presented for treatment as a walk-in patient on July 17, 2002, resulting in
PVAMC clinicians having to amputate part of his left foot on July 25, 2002.
The complainant is a 65-year-old Korean War veteran with a 4-year history of adult onset non-insulin dependent diabetes mellitus. He received medical treatment at the Maryland VA Health Care System's Community-Based Outpatient Clinic in Cambridge, Maryland until he transferred his care to the PVAMC in April 2002. Medical records show that on July 9, 2002, the complainant's primary care physician saw him in the PVAMC Outpatient Clinic. The physician noted an open, 1 X 1 centimeter wound on the ball of the complainant's left foot. Documents show the primary care physician instructed the patient to apply wet-to-dry dressings and keep the wound clean and covered. The primary care physician ordered that the patient be seen in the Podiatry Clinic within 1 week. The physician also prescribed an antibiotic for the complainant to take for 14 days and reordered his pain medication. PVAMC employees told us that the complainant picked up his pain medication, but failed to obtain his antibiotic. It is unclear why the complainant left the pharmacy without the prescribed antibiotic. Pharmacy employees informed us that there is no system in place to inform the prescribing clinician that an ordered medication had not been picked up. All medication is returned to stock if not picked up after 9 days.
On July 16, 2002, while reviewing the complainant's medical record, the primary care physician noted that the Podiatry Clinic appointment he had ordered was scheduled for November 2, 2002, which was the next available appointment. He then sent an electronic mail message to the primary care nurse requesting that the complainant's appointment be rescheduled for an earlier date. Records show that, on July 17,2002, the primary care nurse contacted the complainant. The nurse advised the complainant that his Podiatry Clinic appointment was rescheduled for July 25, 2002. During the telephone conversation, the complainant informed the nurse that his left foot was "...now with red blotches and ... swollen." The primary care nurse advised the complainant to return to the PVAMC that same morning to have an x-ray of his foot as ordered by his physician and to be seen at the Podiatry Clinic. The complainant told the nurse that an employment commitment prevented him from reporting to the Clinic that morning, so the nurse advised him to go to the Emergency Room (ER) or the Primary Care Clinic as soon as possible. Records show that on the afternoon of July 17, 2002, the complainant obtained the foot x-ray at the PVAMC. The complainant then went to the Podiatry Clinic and was told that since he did not have an appointment he would have to be seen by his primary care provider. His primary care provider was not on duty that day, so Primary Care Clinic employees sent the complainant to the ER. The complainant told us that after a 5-hour wait in the ER, he left the PVAMC without being seen.
On July 18, 2002, the complainant was admitted to a local hospital after a police officer stopped him for driving erratically. Local hospital clinicians found the complainant was septic from his foot infection and had a 105degree Fahrenheit temperature. The complainant received treatment at the local hospital where clinicians told him that he would need to have his foot amputated. The complainant left the local hospital against medical advice on July 25, 2002, and returned to the PVAMC ER. PVAMC ER clinicians admitted him for a transmetatarsal amputation.' After the surgery, the patient was discharged without complications....
...we concluded that the complainant did not receive appropriate care on July 17, 2002, because the local procedures to care for walk-ins resulted in the complainant having to present to three different clinical areas and resulted in an ER wait of 5 hours. Despite the complainant's frustration over his long wait for care, the complainant made a poor decision when he left the ER prior to having his infected foot examined. We concluded that the PVAMC walk-in policies combined with the complainant's decision to leave the ER resulted in a less than optimal medical outcome for this veteran...
Our inspection indicated that the primary care physician was hired as a 518 time staff physician who was scheduled to work one afternoon clinic a week and one morning clinic a month. It does not appear that the VA is making proper use of this clinician's time.
Philadelphia 2003 OIG Investigation
This page was last updated on 10/05/2007 01:03 PM
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