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Healthcare Inspection – Alleged Consult Processing Delay Resulting in Patient Death, VA Eastern Colorado Health Care System, Denver, Colorado

Report Information

Issue Date
Report Number
14-04049-379
VISN
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection to assess the merit of an allegation made by a complainant that a consult delay may have resulted in a patient’s death at the VA Eastern Colorado Health Care System (facility), Denver, CO. We substantiated that there was a delay in surgery; however, we could not substantiate that it contributed to the patient’s death. According to the patient’s death certificate, the patient died of natural causes, specifically, hypertension and cardiovascular disease. Without an autopsy, we cannot determine that the patient died of a ruptured aortic abdominal or common iliac artery aneurysm. The patient’s surgery was delayed due to the unavailability of the facility’s endovascular surgeon and the subsequent referral for non-VA medical care. Prior to our site visit, Non-VA Care Coordination (NVCC) managers had identified the possible delay in processing the patient’s NVCC consult and instituted corrective actions. However, we found that there was still confusion between the requesting provider and the NVCC staff in the interpretation of the “urgency” field in the consult request and what it meant to “process” the consult. We made one recommendation.

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 Facility Director ensure that the NVCC consult process is clearly defined, the facility has appropriate processes in place to identify and address potential delays, and that compliance is monitored.