Healthcare Inspection – Communication and Quality of Care Concerns, VA Black Hills Health Care System, Fort Meade, SD

OIG conducted a review in response to allegations received by former Senator Tim Johnson concerning communication with family and the quality of care for a patient at VA Black Hills Health Care System (system), Fort Meade, South Dakota. The complainant alleged that a patient was inappropriately discharged from the system in fall 2013. Additionally, in spring 2014, after the patient was recovering from surgery, system staff failed to contact the patient’s wife when he was transferred from the system’s Emergency Department to a non-VA community hospital, the non-VA community hospital found an abscess under a drain tube, and system staff failed to take the patient’s complaints of a smell from the drain tube seriously. We found that system staff documented appropriate family notification when the patient was transferred from the system’s Community Living Center to the Emergency Department. However, we did not find documentation that the patient’s family was notified as required when he was subsequently transferred from the Emergency Department to a non-VA community hospital. While we substantiated that the patient was discharged from the system and readmitted to a community hospital with multiple medical problems the following day in fall 2013, we did not find that the patient’s discharge from the system was inappropriate. We did not substantiate quality of care concerns related to the presence of an abscess and the failure of system staff to take patient complaints of a smell from the drain tube seriously in spring 2013. We made one recommendation. The Veterans Integrated Service Network and Facility Directors concurred with our recommendation and provided an acceptable action plan.