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Healthcare Inspection – Emergency Department Concerns, Central Alabama VA Health Care System, Montgomery, Alabama

Report Information

Issue Date
Report Number
14-04530-41
VISN
State
Alabama
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted a review in response to allegations of Emergency Department (ED) concerns at the Central Alabama VA Health Care System (CAVHCS), Montgomery, AL. We substantiated that CAVHCS was not meeting the Veterans Health Administration’s ED timeliness measures and that, at times, staff were stretched to provide appropriate special observation to mental health patients in the ED. We did not substantiate that community based outpatient clinic providers refused to see walk-in patients and instead referred them to the ED, that ED patients’ vital signs were not checked as required, that having just one physician on duty in the ED was routinely problematic, that patients were inappropriately referred to other facilities, or that social work staffing in the ED was inadequate. We were unable to fully evaluate seven additional allegations due to insufficient information and/or details. We did not identify conclusive evidence to either sustain or refute these allegations. We made three recommendations.

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 Central Alabama Veterans Health Care System Director charter a systems redesign team to improve the timeliness of care delivery in the Emergency Department.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama Veterans Health Care System Director revise the Emergency Department triage policy to include reassessment expectations for patients designated as Emergency Severity Index levels 2–5.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Central Alabama Veterans Health Care System Director ensure that adequate staffing is available in the Emergency Department to assure safe special observation to mental health patients.