Healthcare Inspection – Quality of Care and Access to Care Concerns, Jack C. Montgomery VA Medical Center, Muskogee, OK

At the request of Senator James Inhofe, OIG conducted an evaluation of several allegations concerning quality of care and access to care at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma. We substantiated some of the allegations regarding quality of care. We substantiated a patient did not receive appropriate treatment for his back pain because of a delay in the diagnosis of a malignancy, which may have been the source of pain. We did not substantiate a failure to provide a patient operative care associated with bleeding gastrointestinal polyps, a failure in VA agreeing to pay for a patient’s open heart surgery resulting in a delay, or a provider’s failure to address leg swelling or a nose bleed affected the rupture of a patient’s “brain aneurysm.” We did not substantiate the VA advised a patient to wait until he tore the remaining two healthy discs in his back and then call 911 to make it a medical emergency. We did not substantiate a delay in scheduling a computed tomography scan and a colonoscopy. We substantiated the access to care allegations. We substantiated a patient experienced poor access to dental services and that the patient was not notified by mail of his scheduled appointment. We also substantiated that another patient experienced poor access to neurosurgical services. We conducted a broad review of the facility’s Non-VA Care Coordination maternity care processes in response to allegations concerning delayed and denied consult requests. While we did not substantiate the allegations, we found that information pregnant patients receive in a facility document as well as the non-VA maternity care providers’ authorization document are potentially ambiguous in wording when applied to select cases. In addition, we found concerns with Dental Services, parking access and safety, and provider documentation of telephone communications. We made eight recommendations.