Healthcare Inspection – Alleged Delayed Mental Health Treatment and Other Care Issues, Kansas City VA Medical Center, Kansas City, MO

OIG conducted an inspection at the request of Representative Kevin Yoder in response to concerns about the extent to which a patient received timely and adequate care for post-traumatic stress disorder (PTSD) and other health care needs at the Kansas City VA Medical Center (facility), Kansas City, MO. We did not substantiate the allegation that the patient was told he would have to wait 30 days for inpatient treatment for PTSD. We found that the patient had multiple health issues and had been screened for admission to another program and assigned an admission date to the other program 35 days after being screened. However, the patient died a few days after acceptance into the program. We substantiated that aspects of the patient’s care were inadequate. In particular, we found that some requests for outpatient consultations were inappropriately cancelled or discontinued, the patient’s abnormal findings and/or care needs were not fully assessed, and appropriate consults were not made when the patient was treated in the Emergency Department. Whether addressing these issues previously would have resulted in a different outcome for the patient is unknown. However, addressing these issues now will help facilitate a more patient-centered environment, especially for those veterans with complex medical and mental health issues. Incidental to our review, we noted that because the facility did not have a signed release of information, staff were unable to discuss the patient’s care with a family member. We made one recommendation to the Interim Under Secretary for Health and three recommendations to the Facility Director. The Interim Under Secretary for Health and the Veterans Integrated Service Network and Facility Directors concurred with our findings and recommendations.