Report Summary

Title: Healthcare Inspection – Alleged Staffing, Quality of Care, and Administrative Deficiencies, Amarillo VA Health Care System, Amarillo, Texas
Report Number: 14-03822-289 Download
Issue Date: 7/6/2017
City/State: Amarillo, TX
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Healthcare Inspection Report
Release Type: Unrestricted

OIG conducted a healthcare inspection at the request of Congressman Mac Thornberry to assess the validity of allegations concerning inadequate staffing, quality of care, and administrative deficiencies. We substantiated that nurse staffing at the facility has not been optimal for several years, but we could not substantiate that inadequate nurse staffing resulted in the death of three patients, an increase in patient falls, or an increase in pressure ulcers. We did not substantiate that the facility closed inpatient beds. We found that the facility diverted patients to non-VA facilities in accordance with its diversion policy. However, facility staff failed to document notification of local Emergency Medical Services (EMS) about the diversion status, and facility leaders did not review diversion data quarterly or provide evidence of performance monitoring.We did not substantiate that low physician staffing was the basis for facility managers’ decision to redirect certain EMS patients. We found that facility managers appropriately coordinated with local EMS to divert heart attack and stroke patients to non-VA facilities better equipped to manage such patients.We did not substantiate that patients’ diagnoses of Chronic Obstructive Pulmonary Disease were inappropriately changed to other diagnoses. We did not substantiate that physician transfer orders were overridden by the Chief Nurse Executive. We did not substantiate that mental health social workers failed to make required weekly visits for three high intensity patients. We also did not substantiate that in October 2013, a patient called the Veterans Crisis Line, requesting an appointment but still had not been seen at the facility by January 2014. We substantiated that the Gastrointestinal Endoscopy clinic had a procedure backlog due to a month long construction project in the endoscopy suite. As of October 2016, we noted that only 8 of 721 procedures were not completed within the time frame specified by the facility.

We substantiated that the facility no longer performed complex surgeries. We could not substantiate that patients were referred to private hospitals for surgeries at their own expense.

We recommended that the Facility Director: Continue efforts to recruit and hire for nursing staff vacancies, and ensure that, until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs. Ensure members consistently attend Pressure Ulcer Committee meetings and document efficacy data on specific treatments, information on new treatment modalities, and action items, to include documentation of follow-up taken regarding action items.