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Healthcare Inspection – Inadequate Follow-Up of an Abnormal Imaging Result, Charlotte Community Based Outpatient Clinic, Charlotte, North Carolina

Report Information

Issue Date
Report Number
15-00190-146
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG reviewed an allegation of improper notification of test results and delayed care at the Charlotte Community Based Outpatient Clinic, Charlotte, North Carolina. We did not substantiate the allegation that the patient was not properly notified of his magnetic resonance imaging results. However, we found that the clinical process of discussing the test results, negotiating a treatment plan, and educating the patient about his condition did not comply with Veterans Health Administration guidelines. We substantiated the allegation that the patient’s treatment was delayed. The primary care provider did not adequately follow up after receiving the patient’s abnormal magnetic resonance imaging results or follow through on the patient’s plan of care. Failure to take clinical action may have contributed to a more complex clinical course for this patient. We made three recommendations.

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 ensure that clinicians involve patients in the treatment planning process and discuss any proposed changes to treatment plans with patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that patients receive education on their medical conditions and that education is documented in the electronic health record.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director evaluate the VA care provided to the patient summarized in this report and confer with Regional Counsel regarding the need for possible disclosure.