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Healthcare Inspection – Poor Access to Care Allegedly Resulting in a Patient Death at the Oxnard Community Based Outpatient Clinic, VA Greater Los Angeles Healthcare System, Los Angeles, California

Report Information

Issue Date
Report Number
14-02890-497
VISN
State
California
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 at the request of Representative Julia Brownley to assess the merit of allegations regarding a delay in a surgical consult at the Oxnard Community Based Outpatient Clinic, VA Greater Los Angeles Healthcare System (the system), Los Angeles, CA, that may have resulted in the death of a patient in August 2012. The complainant alleged that a veteran experienced a delay in surgical consultation for placement of a feeding tube and that the delay resulted in the veteran’s death. We substantiated that the patient experienced a delay in obtaining a surgical consult to address his complaints of dysphagia. We determined that this delay resulted from the primary care provider’s failure to diagnose the patient’s dysphagia timely and/or failure to coordinate the patient’s care by following up on the requested neurology consult, as well as the neurologist’s failure to classify the July 2012 surgical consult as urgent. We could not substantiate that the patient died as a result of the failure to address his dysphagia. The patient did not die in a hospital, and we found no indication that an autopsy was performed. In the course of our review, we found that the system had significant numbers of neurology consults open longer than 90 days. System staff explained that this resulted from a failure to close consults properly after the patients had been seen. However, we determined that the next available appointment in the neurology clinic was approximately 6 weeks in the future, suggesting that some patients may experience delays in obtaining timely neurology consults. We made three 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 Veterans Integrated Service Network Director ensure that the system provides neurology consults within timeframes required by patients' clinical conditions and current Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director monitor provider compliance with timeframes for acting on and closing consults in accordance with the current Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that providers categorize consults based on urgency and that program managers verify the accuracy of categorizations.