Healthcare Inspection – Administrative and Quality of Care Concerns, Martinsburg VA Medical Center, Martinsburg, West Virginia

OIG conducted an inspection to determine the validity of allegations regarding physician leaders’ mismanagement and abuse of power at the Martinsburg VA Medical Center (the facility), Martinsburg, WV. We did not substantiate the allegations that physician leaders overlooked the medical neglect of a patient, denied transfer of critically ill patients, disregarded specialists’ opinions, and gave a nurse authority to delay procedures without informing responsible specialists. However, during the course of our review and separate from the original allegation, we found that the facility failed to provide timely diagnosis and treatment of a patient’s lung cancer. In addition, the facility did not pursue all required administrative procedures in this case. We recommended that the Facility Director ensure that the facility: (1) comply with Veterans Health Administration and facility test results notification requirements, (2) strengthen the root cause analysis process, (3) evaluate the care of the subject patient with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient, and (4) strengthen and monitor the peer review process. The Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided acceptable action plans.