Healthcare Inspection – Substandard Care of a Lupus Patient at the Albany CBOC and Carl Vinson VA Medical Center, Dublin, Georgia

OIG conducted an inspection in response to allegations about mismanagement of patient care at the Carl Vinson VA Medical Center (facility), Dublin, GA. We did not substantiate that a patient with systemic lupus erythematosus was not promptly treated for a urinary tract infection and that the infection contributed to her premature death. The patient did not have test results consistent with a urinary tract infection. We do not know the precise cause of death, but the patient had laboratory evidence consistent with increased lupus activity in the month preceding her death. While facility and contract community based outpatient clinic (CBOC) providers were aware of the patient’s lupus diagnosis, neither acknowledged this significant clinical finding in their progress notes nor consulted a rheumatologist for follow-up. We could not substantiate that the patient was told that the facility would not pay for further care with a private-sector rheumatologist. We were unable to interview the Albany CBOC providers or their supervisors, but the patient’s EHR in the 9 months prior to her death did not reflect discussion of the need for reauthorizing Non-VA care. Therefore, we could not say specifically what the patient was told about future Non-VA care. Based on medical record documentation, it did not appear that either of the Albany CBOC physician assistants who cared for the patient in 2011–2012 ensured that she received appropriate continuity of rheumatology care. Responsible facility clinicians and managers did not comply with guidelines for completing peer reviews, and as a result, the peer review of this case did not address the full scope of quality issues contributing to the patient’s outcome. OIG made four recommendations.