Report Summary

Title: Quality and Coordination of a Patient’s Care at the VA Eastern Colorado Health Care System, Denver, Colorado
Report Number: 18-01455-108 Download
Issue Date: 4/11/2019
City/State: Denver, CO
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) reviewed a complainant’s allegations and substantiated that the facility’s providers, at the time of a patient’s most recent hospital admission, failed to complete thorough evaluations including reconciliation of medications. The incomplete evaluation may have contributed to the patient’s declining health and likely hindered the provision of additional needed treatment.

Providers failed to appropriately treat the patient’s underlying condition or recognize potential signs of illness such as an elevated white blood cell count. The OIG would have expected the providers to identify and remove the source of infection. The OIG was unable to determine whether the providers’ failures contributed to the patient’s death.

The OIG was unable to determine whether system providers discharged the patient without a discussion with the family of the patient’s medical condition. However, the patient was competent and was included in care discussions; including family members in the discussions was not required. The OIG substantiated that providers did not communicate care options to mitigate the patient’s suffering.

In addition, podiatry clinic staff did not consistently follow system policy for scheduling appointments and wound care clinic consults were not performed as required. Coordination of care expected for a geriatric patient with chronic illnesses, multiple wounds, and who was “at risk” for foot ulcers was lacking and care was fragmented. Deficiencies in the patient’s care coordination likely contributed to the patient’s worsening wounds.

The podiatry attending physician did not document resident supervision in accordance with system policy.

The OIG made eight recommendations related to medication reconciliation, provider education, infection source, care transitions, discharge planning, podiatry clinic scheduling, wound care clinic consults and practices, and resident supervision.