Report Summary

Title: Healthcare Inspection – Delay in Care of a Lung Cancer Patient, Phoenix VA Health Care System, Phoenix, Arizona
Report Number: 14-00875-325
Issue Date: 9/30/2016
City/State: Phoenix, AZ
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: At the request of Senator Jeff Flake, OIG conducted an inspection to determine the merit of allegations regarding a delay in treating a patient diagnosed with lung cancer at the Phoenix VA Health Care System, Phoenix, AZ. We substantiated a delay between the diagnosis of the lung cancer and treatment. We could not determine whether this delay impacted the final outcome. We substantiated a delay in identification of symptoms of cancer metastasis; however, we did not substantiate a delay in treatment once the brain metastasis was discovered. We identified lack of patient education and primary care provider involvement in the coordination of subsequent cancer-related specialty appointments as factors contributing to delays in care.
We did not substantiate the allegation that following his craniotomy there was a failure to communicate the patient’s status to the patient and family. The patient and his family received accurate information regarding his status and the plan to transition the patient to a non-VA nursing home and place him in hospice. We did not substantiate a failure to adequately manage the patient’s pain. Pain management monitoring, decisions, and education were documented in the electronic health record. We identified several additional issues during our review. The patient’s risk for depression was not fully assessed following the new diagnosis of lung cancer. Although the EHR contained evidence that system providers were aware of results of non-VA testing, non-VA medical records were not consistently available in the electronic health record. Service agreements were not active for the oncology and neurology services. Consults placed during the course of the patient’s treatment were designated with routine urgency even though the clinical expectation and actual need was for a more urgent response. We made seven recommendations.