Delays in Diagnosis and Treatment and Concerns of Medical Management and Transfer of Patients at the Fayetteville VA Medical Center, North Carolina

This healthcare inspection assessed the delay and treatment of a patient diagnosed with leukemia (Patient A) and a failed inter-facility transfer. Inspectors also reviewed a second patient’s (Patient B’s) admission and inter-facility transfer. Facility leaders’ oversight and response to the events as well as ongoing professional practice evaluations (OPPE) were also reviewed. The Office of Inspector General (OIG) determined that a primary care provider failed to act on Patient A’s abnormal laboratory results and pathologists’ recommendations for follow-up testing and hematology consultation. Community Care staff did not process a consult and schedule Patient A’s appointment. The OIG was unable to determine whether there was a delay in diagnosing and treating Patient A’s leukemia; it is unknown if earlier bone marrow biopsy results would have yielded a definitive diagnosis and treatment options. During hospitalization, Patient A developed a gastrointestinal bleed. Providers initiated an inter-facility transfer. While awaiting transfer, the patient became unresponsive and died. A hospitalist failed to initiate the emergency transfer protocol, delaying Patient A’s transfer. The facility’s policy did not reflect available treatment capabilities. The Administrative Officer of the Day’s response to an emergency medical service dispatch call delayed Patient B’s inter-facility transfer. Patient B was transported but arrived in cardiac arrest and also died. The OIG was unable to conclude whether the delay affected Patient B’s outcome. Facility leaders did not initiate comprehensive analyses of events surrounding the patients’ deaths or related processes. Frequent executive leadership changes impeded the resolution of systemic issues. The hematologist’s OPPE also was not completed by a provider with similar training and privileges. The OIG’s 12 recommendations to the Facility Director addressed primary care provider responses to abnormal laboratory results, community care consult processing, policy updates and staff training on treating and transferring patients with emergency conditions, facility responses to the events, and OPPE.