Alleged Inappropriate Anesthesia Practices at the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complainant’s allegations regarding an anesthesiologist who provided outpatient sedation services at the James E. Van Zandt VA Medical Center (Facility), Altoona, Pennsylvania. The OIG did not substantiate an allegation that the anesthesiologist failed to follow Veterans Health Administration (VHA) and Facility policies for controlled medication waste because the anesthesiologist documented that the entire amount was used. The OIG did not substantiate an allegation that the anesthesiologist failed to individualize patient medication dosing. The OIG substantiated allegations that the anesthesiologist used more anesthetic/sedation medication for outpatient procedures than Food and Drug Administration approved manufacturer’s instructions recommended, and Facility leaders did not provide oversight of the anesthesiologist according to VHA and Facility privileging and ongoing monitoring policies. The OIG determined that the Facility needs to reevaluate if the provider should be reported to the National Practitioner Data Bank or State Licensing Board for administering medications that were inconsistent with Food and Drug Administration approved manufacturer’s dosage instructions. Additionally, OIG staff determined that the anesthesiologist did not follow Facility policy for pre-procedure documentation for 14 of 20 identified patients and for transfer of a patient who required general anesthesia to a designated VA or non-VA Facility. In reviewing the Facility’s documented patient complaints, OIG staff did not find complaints regarding the anesthesiologist; however, the Facility’s Patient Advocate did not document and track complaints on the Patient Advocate Tracking System as required by VHA. The OIG made four recommendations related to anesthesia needs and services, provider oversight, National Practitioner Data Bank and State Licensing Board reporting, and Patient Advocate Tracking Systems database requirements.