Report Summary

Title: Healthcare Inspection - Respiratory Care and Other Clinical Concerns, VA Northern Indiana Health Care System, Fort Wayne, IN
Report Number: 11-03462-17
Issue Date: 10/24/2012
City/State: Ft. Wayne, IN
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an inspection to determine the validity of anonymous complainants’ allegations regarding inappropriate respiratory and clinical care at the VA Northern Indiana Health Care System, Fort Wayne, IN. We determined that the clinical care provided was appropriate. We substantiated the allegation that respiratory care policies were absent or ignored, and found that oxygen therapy was being initiated without a provider order. We substantiated that an identified physician had a higher readmission rate than other facility physicians, and also found that the Peer Review Committee did not ensure specific actions are taken in response to deficiencies identified. We did not substantiate the allegations that another physician admitted patients with a diagnosis of pneumonia without obtaining appropriate diagnostics tests, patients were overmedicated due to short staffing, staff were leaving due to inferior patient care, and when patients became Do Not Resuscitate they were considered do not treat. We could not determine if arterial blood gases (ABGs) are performed when not indicated because there was no written criteria for ordering ABGs. We recommended that the facility Acting Director ensure that facility respiratory care policies are updated, including specific guidance and expectations for ordering oxygen therapy; that peer review processes comply with VHA policy; and that an assessment of ABG usage is completed.