Report Summary

Title: Healthcare Inspection – Inconsistent Transfer Procedures for Urgent Care Clinic Patients with Stroke Symptoms, Manchester VA Medical Center, Manchester, New Hampshire
Report Number: 15-03288-362 Download
Issue Date: 9/7/2017
City/State: Manchester, NH
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted a healthcare inspection to evaluate stroke care at the Manchester VA Medical Center (facility), Manchester, NH pursuant to an April 2015 request of Congresswoman Ann McLane Kuster. The request was in response to a Federal court ruling that the facility failed to adequately diagnose and treat a stroke patient when he presented to the Urgent Care Clinic (UCC) in 2010. The purpose of the review was to determine whether system issues may have led to poor care of the patient and to evaluate changes that the facility may have made in response to this incident.

We found that the patient should have been transferred to another facility with the capability to perform a complete diagnostic workup and care for stroke patients (acute care facility) and should not have received any diagnostic evaluations at the facility.

We found deficiencies with facility’s Peer Review process. Discussion of the specifics of the deficiencies is prohibited by 38 U.S.C. §5705.

To determine compliance with VHA and facility policy and assess whether the system issues from 2010 remain today, we reviewed the records of 23 patients who presented to the UCC with a presumptive stroke between June 2014 and May 2015. UCC providers did not always transfer patients prior to conducting a diagnostic test and did not always designate the patient's primary care provider as a co-signer of the UCC discharge summary. When UCC providers transferred patients with a presumptive stroke to an acute care facility, they did not consistently observe facility managers' expectations to transfer patients to a non-VA acute care hospital, approximately 2.5 miles away (closest acute care hospital).

During a follow-up site visit in February 2016, we found that facility managers made system and procedural changes in the UCC.

We made three recommendations.