Report Summary

Title: Healthcare Inspection - Alleged Patient Rights, Quality of Care, and Other Issues, VA Puget Sound Health Care System, Seattle, Washington
Report Number: 13-02235-277
Issue Date: 8/13/2013
City/State: Seattle, WA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: At the request of Senator Patty Murray, the Office of Inspector General (OIG) Office of Healthcare Inspections conducted an evaluation in response to allegations brought forth by a patient related to a dermatology examination the patient received at the Seattle Division of the VA Puget Sound Healthcare System, Seattle, WA.
We did not substantiate that the examination was unnecessary as alleged. However, we found the provider did not ensure a chaperone was present during the examination as required. We did not substantiate allegations that the provider nudged and pushed the patient, did not wash her hands, or had ragged and unkempt fingernails. We substantiated that the provider did not wear gloves during the examination as alleged, but determined the use of gloves was not indicated and that this was appropriate practice. We substantiated that the window in the examination room was not covered, but determined the window was not covered to aid the provider’s diagnostic exam and it was unlikely the patient’s privacy was breached. We found that system staff did not fully respond to the patient’s concerns and did not report the patient’s allegations in accordance with Federal regulation and VHA policy.
We recommended the System Director ensure the Women Veterans Program Manager provides chaperone policy education to all primary care clinics. We also recommended the System Director ensure all staff are informed about the VHA requirement to report allegations of patient abuse and educated on the processes for reporting the alleged abuse.