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Postoperative Care Concerns for a Vascular Surgical Patient at the Martinsburg VA Medical Center, West Virginia

Report Information

Issue Date
Report Number
17-05381-258
VISN
State
West Virginia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senator Joe Manchin to review the postoperative care of a patient (Patient) who had vascular surgery at the Martinsburg VA Medical Center (Facility), West Virginia. In general, the OIG found the Patient’s immediate postoperative care was proper. However, the OIG had concerns with the Patient’s management at the Community Based Outpatient Clinic (CBOC) 10 days after the procedure when the Patient presented with signs and symptoms of a known vascular procedure complication. After an endovascular aneurism repair (EVAR), the Patient’s clinical condition was consistent with cholesterol embolization syndrome which has no accepted specific therapy. On EVAR post-operative day (POD) 14, the Patient had amputations of three toes and was noted to have infection in the amputated bone. The OIG could not determine if earlier toe amputations would have prevented the bone infection. On POD 10, after determining the Patient was experiencing a medical emergency, CBOC patient aligned care team staff did not ensure coordination of the Patient’s subsequent care. Staff failed to facilitate a safe transition between the CBOC and a non-VA hospital equipped to treat the Patient. Staff did not communicate relevant information or provide health record information to providers at the non-VA hospital upon learning where the Patient planned to seek emergency treatment. The OIG found deficiencies in Veterans Health Administration policy compliance with the lack of policy or standard operating procedure on the management of health emergencies in the CBOC and inconsistent health record documentation for the Patient. The OIG made three recommendations related to coordination of care, health emergency management, and health record documentation.

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 Martinsburg VA Medical Center Director evaluates the coordination of care processes at the Petersburg Community Based Outpatient Clinic and takes action as necessary based on the findings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures the development and implementation of a policy or standard operating procedure for the management of health emergencies at the Petersburg Community Based Outpatient Clinic, and Petersburg Community Based Outpatient Clinic staff receive training on the policy or standard operating procedure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director evaluates the Petersburg Community Based Outpatient Clinic Patient Aligned Care Team patient health record documentation for accurate and clinically-relevant statements and takes action as necessary based on the findings.