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Healthcare Inspection – Quality of Care Issues, Sheridan VA Healthcare System, Sheridan, Wyoming

Report Information

Issue Date
Report Number
14-00903-422
VISN
State
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection to review quality of care allegations at the Sheridan VA Healthcare System, Sheridan, WY. We could not substantiate the allegation that the facility did not adhere to clinical care recommendations previously identified by the facility for the management of a patient’s dysphagia (difficulty swallowing). Documentation indicated staff knowledge of the patient’s risk for aspiration; however, electronic health records do not provide conclusive evidence of steps taken to manage the patient’s dysphagia. We found that the facility lacked a mechanism that would assist staff in quickly detecting previously identified dysphagia and aspiration risk. We found that the patient’s respiratory distress was not adequately addressed after admission in the hours immediately prior to the patient’s death. We did not substantiate that the patient received a suprapubic catheter to ease the patient’s care for previous caregivers, that the facility failed to adequately address the patient’s care needs as an outpatient causing him to become more acutely ill before being admitted, or that the facility refused to provide physical therapy for the patient. We were also unable to substantiate that the facility refused to receive the patient via ambulance on multiple occasions. We found opportunities to align actual practice in the area of provider privileging with local facility and Veterans Health Administration policy. We recommended that the Facility Director: (1) ensure that staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment, and documentation of the patient’s response to the provided care recommendations and aspiration risk precautions; (2) implement applicable recommendations from previous event-related reviews, if any; and, (3) review local credentialing and privileging processes to ensure compliance with Veterans Health Administration Handbook 1100.19. The Veterans Integrated Service Network and Facility Directors concurred with our findings and recommendations.

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 staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment and documentation of a patient's response to the provided care recommendations and aspiration risk precautions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director implement applicable recommendation(s) from previous event-related reviews, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director review local privileging processes and ensures compliance with local policy and Veterans Health Administration Handbook 1100.19.