Alleged Complications Associated with Phototherapy at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi

Report Information

Issue Date
Report Number
17-03399-140
VISN
State
Mississippi
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to the care provided to a patient who was mistakenly treated with phototherapy for bed bugs and developed complications. Two days after receiving the phototherapy treatment, the patient was hospitalized for first degree (outer layer of the skin) and second degree (deeper layers of the skin) burns. Phototherapy is ordered by a dermatologist after diagnosis of a skin condition that would be responsive to treatment. Phototherapy is not indicated for the treatment of patients with bed bugs. A dermatology clinic registered nurse (RN) provided phototherapy to the patient for the treatment of bedbugs without a provider assessment and order, even though a dermatologist was available for assessment the day of treatment. Facility staff improperly attributed the need for action to its Integrated Pest Management policy that guides environmental actions. Despite an appendix to the policy that stated, “there is no specific medical treatment for bed bugs,” facility staff pursued a clinical treatment, phototherapy, for the patient. Facility leaders initiated a fact-finding review. The review’s charge letter was unclear regarding its confidential or non-confidential status. Confidential reviews may not be used as a basis for administrative action. The OIG made two recommendations to the Veterans Integrated Service Network 16 Director related to fact finding reviews conducted at the Gulf Coast Veterans Health Care System. The OIG made five recommendations to the Gulf Coast Veterans Health Care System Director related to dermatology clinic nurse practice requirements, training, and competencies; a review of the Gulf Coast Veterans Health Care System’s policy related to environmental actions following identification of bed bugs; necessary training related to the policy; and completion of Gulf Coast Veterans Health Care System’s actions recommended by an internal review.

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 Gulf Coast Veterans Health Care System Director confirms current dermatology clinic nursing practice requirements related to ensuring informed consent prior to initiating phototherapy are followed and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Gulf Coast Veterans Health Care System Director ensures dermatology clinic registered nurse training and competencies are completed as required and tracked for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Gulf Coast Veterans Health Care System Director reviews facility policy to ensure guidance clearly delineates environmental actions to be taken following identification of bed bugs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Gulf Coast Veterans Health Care System Director ensures that all Gulf Coast Veterans Health Care System staff are trained on the policy addressing environmental actions to be taken following identification of bed bugs and track compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Gulf Coast Veterans Health Care System Director ensures that the Patient Safety Manager completes all actions identified in the subject adverse event review.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 16 Director reviews the Gulf Coast Veterans Health Care System policy related to the confidentiality of fact-finding reviews to evaluate if the initiation of such reviews, including the one conducted in relation to this patient, is consistent with the purpose of maintaining the confidentiality of quality management activities, and takes action as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 16 Director reviews and evaluates the proposed and actual disciplinary actions taken by Gulf Coast Veterans Health Care System managers related to the events of the day in question, and takes action as appropriate.