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Healthcare Inspection – Ophthalmology Service Concerns, VA Illiana Health Care System, Danville, Illinois

Report Information

Issue Date
Report Number
14-02412-69
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection to assess the merit of allegations made by an anonymous complainant about the Ophthalmology Service at the VA Illiana Health Care System (facility), Danville, IL. We did not substantiate that surgery was performed on the wrong eye of a patient, or that the ophthalmologist ordered an antibiotic late. We did not substantiate that the patient’s death was due to two eye infections or that the facility Mortality and Morbidity Committee “covered up” issues related to the patient. We did not substantiate that an ophthalmologist was using unsterile instruments. We did not substantiate that the ophthalmologist did not perform retinal exams or treat glaucoma due to an inability to read optical coherence tomography tests. We substantiated that the ophthalmologist saw a patient in her private practice but the patient was sent back to the VA appropriately. We did not substantiate that patients were referred inappropriately to private practices. We substantiated that patients were not referred back to the facility’s Optometry Service after surgery, but this was appropriate for workflow reasons. We substantiated that the ophthalmologist was taking VA patient records to her private practice; however, the facility was aware, and personally identifiable information was protected. We noted that three investigations showed serious interpersonal problems amongst the staff and providers of the service, but recommended actions had not been taken. We recommended that all recommendations for interpersonal training for the staff and providers in the Ophthalmology and Optometry Services be implemented.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement all recommendations for interpersonal training for the staff and providers in the Ophthalmology and Optometry Services.