Report Summary

Title: Healthcare Inspection - Clinical and Administrative Allegations Involving Surgical Service, Carl Vinson VA Medical Center, Dublin, GA
Report Number: 12-02277-49
Issue Date: 11/28/2012
City/State: Dublin, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an evaluation to determine the validity of allegations related to inadequate communication and delayed interfacility patient transfers between the Carl Vinson VA Medical Center, Dublin, GA, and the Charlie Norwood VA Medical Center (VAMC), Augusta, GA. We did not substantiate the allegation that facility providers gave inaccurate patient information to the Charlie Norwood VAMC prior to a patient’s transfer for neurosurgical evaluation. We found documentation in the patient’s electronic health record to support that appropriate information was communicated to the Charlie Norwood VAMC.
We did not substantiate the implication that a patient’s colon perforation was the result of the physician’s non Board-certified status. We could not confirm or refute that delay and transfer issues resulted in a patient’s death. During the course of our review, we identified opportunities to improve the facility’s provider reprivileging processes, as well as the collection and analysis of aggregated surgical complication data. We recommended that provider reprivileging processes be conducted in accordance with VHA guidelines. We also recommended that the Operative and Other Procedures Review Committee collect and analyze aggregate surgical complication data to identify trends and patterns, and take appropriate corrective action when indicated.