Healthcare Inspection – Quality and Coordination of Care Concerns at Two Veterans Integrated Service Network 15 Facilities

OIG conducted an inspection to review allegations regarding the quality and coordination of care of a patient at the Kansas City VA Medical Center (VAMC), Kansas City, MO, and the Kirksville VA Clinic, a Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO clinic. We substantiated that the patient experienced multiple hip dislocations after replacement surgery. The recurrent hip dislocations resolved after revision surgery. We did not substantiate that the Kansas City VAMC delayed payment for ambulance transportation. We substantiated that the patient’s evaluation for potential aortic aneurysm repair was delayed, but did not substantiate that the aortic aneurysm probably resulted in his death or that VA providers inappropriately postponed surgical repair. We substantiated that the patient did not receive appropriate evaluation for recurrent falls and weakness; additionally, his primary care provider did not follow usual practice in prescribing medications associated with increased fall risk. We could not substantiate that the patient was involved in a motor vehicle accident at the VA. We found reports of a fall but no reports of a motor vehicle accident for the specified date. We substantiated that prescriptions were mailed to the patient after his death. We reviewed pharmacy data files to determine whether medications were being dispensed after patients’ deaths across Veterans Health Administration. We found that 17.2 percent of patients, or 29,173 patients, who died between July 1, 2013, to June 30, 2014, were dispensed at least one prescription after death on the average of 33 days after death; 96 percent of the dispensed medications were for non-controlled substances. We could not substantiate the allegation that the patient was denied care three times at the Kirksville CBOC. We made five recommendations. The Interim Under Secretary for Health, Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided acceptable action plans.