Healthcare Inspection – Alleged Quality of Care Issues and Communication Lapses, Washington DC VA Medical Center, Washington, DC

The VA Office of Inspector General Office of Healthcare Inspections conducted a review to determine the validity of allegations regarding a patient’s quality of care and communication between professional staff and a patient’s family at the Washington DC VA Medical Center. The complainant alleged that treatment of the patient’s urinary tract infection was delayed; that the facility did not tell the family the patient had a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection; that the patient was released from outpatient care despite the MRSA infection; and that communication with the family about all of the patient’s conditions was poor. We substantiated that management of the MRSA urinary tract infection was not timely instituted. We found that the facility did not conduct a Quality Review for the outpatient MRSA management issue. We substantiated that the patient and family were not timely notified of the patient’s MRSA infection while he was an outpatient. We did not substantiate the allegation that the facility lacked professionalism in relating to the patient’s family. We recommended that the facility Director, in accordance with VHA Handbook 1004.08, consult with Regional Counsel regarding institutional disclosure to the patient’s family; ensure that a quality of care review is conducted with specific attention to deficiencies identified in this report; and monitor providers’ documentation to ensure compliance with VHA policies on information management and health records.