Healthcare Inspection – Alleged Misdiagnosis and Delay in Treatment, Providence VA Medical Center, Providence, Rhode Island

OIG conducted a healthcare inspection to evaluate allegations that a provider at the Providence VA Medical Center, (facility) Providence, RI, misdiagnosed a patient’s Achilles tendon rupture (ATR) in 2014 leading to a delay in treatment and further injury to the tendon. We substantiated that, on two occasions, an Emergency Department (ED) provider did not respond to a patient’s complaint that he may have an ATR and misdiagnosed him with a sprained ankle. The provider did not fully assess the patient’s injury (did not conduct a common definitive test used to identify a potential ATR) and is diagnosed the injury as a sprained ankle. We substantiated that the sprained ankle misdiagnosis caused a 16-day delay in treatment of the ATR. We could not substantiate that the misdiagnosis, delay in treatment for the ATR, and the treatment prescribed for a sprained ankle versus an ATR in the ED worsened the injury. A delay in ATR diagnosis or treatment may result in a worse outcome. Providers utilize a combination of ATR-specific clinical assessments and tests to diagnose and determine the extent of an ATR. However, because the ED provider did not document the proper assessments, which would have provided a clinical baseline of the ATR, we could not discern whether the injury became worse during the 16 days the patient was treated for a sprained ankle. Besides the 16-day delay, we identified other timeframes when different treatments affecting optimal outcomes could have occurred. The initial assessment occurred 3 days after injury. The patient was given options for conservative or surgical treatments within 4 weeks of injury and pursued conservative treatment. The patient had complaints of persistent pain after 6 months of conservative treatment and subsequently decided to undergo Achilles tendon surgery. We could not determine the extent to which the 3 day delay in seeking treatment, the 16-day delay in diagnosis, and/or the 6 month delay occasioned by the patient’s initial choice of non-operative treatment contributed to unfavorable healing. We found a peer review was done but documentation of the peer review process was incomplete. We identified that the Chief of Emergency Medicine did not follow up on the patient’s complaint about his first ED visit. We recommended that the Facility Director (a) ensure that peer reviews are completed as required by the Veterans Health Administration and (b) strengthen processes to ensure that patient complaints are resolved in accordance with facility policy.