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Healthcare Inspection – Alleged Quality of Care and Courtesy Issues at the Alamosa Community Based Outpatient Clinic, Alamosa, Colorado

Report Information

Issue Date
Report Number
14-00615-61
VISN
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection to determine the validity of allegations of quality of care and lack of courtesy provided to a patient at the VA Eastern Colorado Health Care System’s Alamosa Community Based Outpatient Clinic (CBOC). The complainant alleged that a nurse did not adequately assess and triage a patient because the patient presented late on a Friday afternoon and that the nurse treated the patient with disrespect, sarcasm, and a lack of compassion. It was also alleged that CBOC staff attempted to contact the patient through his brother instead of the emergency contact on file for the patient. We did not substantiate that a nurse did not adequately assess the patient; however, we substantiated that the nurse did not appropriately triage the patient to a higher level provider based on that assessment. A physician later determined that the patient had not been appropriately triaged and took action to advise the patient to seek additional medical care; however, managers did not address the nurse’s failure to appropriately triage the patient. CBOC staff reported that they were unaware of formal policies or procedures for the triage of walk-in patients. We could not substantiate that the CBOC nurse was disrespectful, sarcastic, or uncompassionate to the patient. We could not substantiate that a CBOC staff member contacted the patient’s brother instead of the emergency contact listed in the patient’s electronic health record. We made two recommendations to the Director of the VA Eastern Colorado Health Care System.

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 the CBOC triage guidelines and train staff on the guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that managers appropriately address CBOC staff who exhibit lapses in competency, when identified.