A Delay in Patient Notification of Test Results and Other Communication Issues at the Bath VA Medical Center, New York

The VA OIG conducted a healthcare inspection to assess allegations of delays in providing patient test results, communication issues between providers and paramedics related to transporting patients to a community hospital emergency department, violations of the Emergency Medical Treatment and Labor Act, and quality of care concerns resulting from paramedic care at the Bath VA Medical Center (facility). The OIG substantiated a surrogate provider failed to follow test notification policies when a patient received positive stress test results 36 days after the test; however, the patient did not experience an adverse event as a result. The OIG substantiated a paramedic failed to comply with the facility’s standard operating procedure when the paramedic transported a patient to the nearest community hospital rather than one instructed by the provider. The provider recommended a hospital that was further because the nearest one lacked the necessary equipment to complete the patient evaluation. The OIG team noted that the facility’s transfer policy did not clearly define a process for outpatient transfers to a higher level of care utilizing facility paramedics. The OIG did not substantiate that facility paramedics violated the intent of the law by transporting patients to a community hospital emergency department. Facility providers medically screened and provided care to the patients prior to transfer. The OIG did not substantiate that facility paramedics provided poor quality of care to the reviewed patients. The paramedics asked suitable and clarifying questions of the providers, assessed the patients, and documented their findings. The OIG made two recommendations to the Facility Director to ensure that surrogate providers comply with their responsibilities to notify patients of test results when providing coverage and to ensure that the Patient Transfer Policy clearly defines a process for outpatient transfers to a higher level of care utilizing facility paramedics.