Report Summary

Title: Alleged Clinical and Administrative Concerns Involving a Wound Care Provider in Veterans Integrated Service Network 21
Report Number: 18-05264-58 Download
Issue Date: 1/24/2019
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection at a Veterans Integrated Service Network 21 medical facility in response to a complaint alleging that a provider’s deficient practices placed patients at risk for poor outcomes, the provider mismanaged clinic time and associated resources, and system leaders had not been fully responsive to these concerns.

The provider did not order stat venous ultrasounds on three patients with suspected deep vein thrombosis (DVT). However, this failure did not violate clinical or professional guidelines. Still, the provider did not document clinical assessment of pretest probability of patient risk for DVT, as recommended by guidelines to direct additional testing and treatment. Two of the three patients subsequently tested positive for DVT.

Supplies were removed from the system’s secure storage device used for medical supplies without proper accounting of the items. However, the failure could not be attributed to a specific user or users. The OIG substantiated that the provider completed a telephone consult rather than seeing the patient, but the team found this to be reasonable under the circumstances.

The OIG was unable to determine whether the provider consistently adhered to good infection control practices, used high-cost items unnecessarily, arrived late and left early from clinic, or improperly accepted a gift.

The OIG did not substantiate that the provider “padded” clinics, did not follow the diabetic foot ulcer algorithm, and failed to evaluate a patient prior to his cardiopulmonary arrest. Further, the OIG did not substantiate that system leaders failed to hold the provider accountable for alleged quality deficits or improper actions. System leaders conducted reviews and took appropriate actions as needed.

One recommendation was made to evaluate the care of the two patients with suspected DVT to determine whether opportunities for more timely diagnosis of DVT existed.