Healthcare Inspection – Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego Healthcare System San Diego, California

OIG conducted an inspection to evaluate the circumstances surrounding the death of a patient at the VA San Diego Healthcare System (system), San Diego, CA. The Office of Healthcare Inspections evaluated the quality of care provided for the patient prior to his suicide. The Office of Audits and Evaluations assessed whether the San Diego VA Regional Office (VARO) Rating Decision accurately decided the patient’s compensation claim. We determined that the quality of care provided for the patient’s chronic pain did not adhere to the VA/DoD clinical practice guidelines. We determined that the patient was newly diagnosed with traumatic brain injury and post-traumatic headaches during a Compensation and Pension examination in January 2014, but there was no follow-up plan to address these issues. Although the San Diego VA Regional Office decided the patient’s claim prematurely without obtaining all relevant service treatment records, we did not find that the outcome of the patient’s compensation claim was incorrect. We recommended that the Under Secretary for Health ensure that Compensation & Pension examiners document that patients with new diagnoses are counseled on the need for follow-up care and provided assistance in obtaining VA care, and that all clinically relevant communications are documented in the electronic health record; the System Director implement processes to ensure that providers adhere to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, including follow-up assessment at appropriate intervals, when treating patients with chronic opioid therapy, and confer with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient; and the San Diego VA Regional Office Director review a sample of the specific rater’s work and determine whether failure to obtain relevant service treatment records is a systemic issue with this rater when making compensation claim decisions.