Breadcrumb

Healthcare Inspection – Care of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin

Report Information

Issue Date
Report Number
15-02456-396
VISN
State
Wisconsin
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection at the request of Senator Tammy Baldwin and Senator Ron Johnson to assess allegations of poor care and delayed care of a patient in the Tomah VA Medical Center (VAMC) Urgent Care Clinic (UCC) in Tomah, WI. We did not substantiate the general allegations of poor care and delayed care; that the patient waited 3 hours before being seen; that other patients arrived, were treated and released before the case patient; that a physician was unaware of acute ischemic stroke symptoms and treatment; or, that the Tomah VAMC computerized tomography machine was broken. We substantiated the allegation that the physician did not affirmatively diagnose the first neurologic event the patient experienced as a transient ischemic attack or acute ischemic stroke; however, the physician properly considered broad diagnostic possibilities for the syncopal episode, which occurred while the patient was in the Tomah VAMC UCC waiting room awaiting a mental health evaluation. We did not substantiate that the physician failed to treat the patient’s second neurologic event, an acute ischemic stroke, with sufficient urgency. We determined that transferring the patient to Gundersen Health System by ground ambulance was the appropriate action after a stroke was definitively diagnosed. We found that the Tomah VAMC does not own or operate an air ambulance and that one was not available to transfer the patient. We concluded that, overall, the UCC staff acted appropriately in the face of a patient experiencing a sudden and unexpected acute ischemic stroke while waiting for a mental health evaluation in a rural hospital that is not equipped to treat a health problem of this magnitude. We identified opportunities for improvement, none of which impacted this patient’s care, and made three recommendations to the Under Secretary for Health and six recommendations to the Tomah VAMC Director.

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 Under Secretary for Health review current acute stroke treatment policies, and assess the use of telehealth evaluation and more aggressive local treatment in patients presenting to rural and/or low complexity VHA facilities with signs and symptoms of an acute stroke.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health review processes to improve the ability to identify unauthorized access to VA medical records.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health evaluate the complex rules related to reimbursement for a veteran’s emergency care at non-VA facilities, and determine if changes in policy or law would make it more likely that veterans would make decisions on where to seek emergency care based upon medical circumstances, rather than fear of adverse financial impact.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that patients and their families are educated about the services the UCC is equipped to provide.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that employees who are involved in assessing and treating stroke patients receive the web-based acute ischemic stroke training required by the facility and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that transfer agreements are established as required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.