Breadcrumb

Alleged Mismanagement of Inpatient Care at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas

Report Information

Issue Date
Report Number
17-02484-189
VISN
State
Kansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The Office of Inspector General (OIG) conducted a healthcare inspection at the Colmery-O’Neil VA Medical Center (Facility) in Topeka, Kansas, regarding an anonymous complainant’s allegations that physicians were practicing beyond their clinical privileges and expertise; physicians failed to seek assistance from specialists, thus placing patients at risk; and a nurse practitioner did not have physicians’ help or supervision for the inpatient medical service. The OIG did not substantiate that physicians were practicing beyond their clinical privileges and expertise. However, two providers were granted clinical privileges that exceeded the Facility’s operative and Intensive Care Unit complexity levels. Although the OIG did not substantiate that physicians failed to seek assistance from specialists, specialty care clinics had only one provider to cover each area. The OIG determined that specialty services’ consults were ordered when medically necessary, patient transfers were timely and clinically indicated, and inpatients were transferred if specialists were unavailable. The OIG did not substantiate that a nurse practitioner covered the entire inpatient medical service without help or supervision. Additionally, the OIG determined that the VA Eastern Kansas Health Care System’s bylaws had not been updated to reflect VA’s 2017 amendment to its medical regulations permitting full practice authority for Advanced Practice Registered Nurses. The Facility did not meet Veterans Health Administration surgical complexity requirements for surgeons or anesthesia service. Facility staff could not provide lists of after-hours on-call social workers, mental health staff, specialists, and radiologists. Ultrasound scans were not available during all emergency department hours. The OIG made six recommendations related to providers’ clinical privileges; updating bylaws; requirements for after-hours surgeon staffing, pre-operative risk and anesthesia assessments, and anesthesia service coverage; specialty care consults’ timeliness; on-call specialists’ availability; and timely emergency department specialty resources.

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)
The System Director ensures provider privileges are facility-specific as required by Veterans Health Administration Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director ensures the System’s Bylaws and Rules of the Medical Staff are updated to reflect compatibility and compliance with 38 CFR 17.415, Full Practice Authority for Advance Practice Registered Nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director ensures the Facility meets the requirements for physician staffing for inpatient coverage, pre-operative risk and anesthesia assessments, and anesthesia services in-house coverage as required by Veterans Health Administration Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, May 6, 2010.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director reviews the timeliness of specialty care consults and ensures that specialty consults are provided timely as required by Veterans Health Administration policy, including the use of service/care coordination agreements as necessary to define time frames.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director ensures the Facility provides a list to the Emergency Department and inpatient staff of appropriate on-call social work and mental health staff, as well as specialty physicians, including radiologists, as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The System Director ensures the Facility provides and monitors the availability and timely response of specialty consultants and ultrasound services in the Emergency Department as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).