Deficiencies in Evaluation, Documentation, and Care Coordination for a Bariatric Surgery Patient at the VA Pittsburgh Healthcare System in Pennsylvania

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations of inadequate preoperative evaluations and the management of postoperative care for a patient approved for bariatric surgery at the VA Pittsburgh Healthcare System. The patient did not receive three required laboratory tests prior to bariatric surgery; however, the OIG did not substantiate that the patient was inappropriately approved for surgery. These omissions did not affect the clinical indication for surgery or the outcome. The OIG did not substantiate that the patient was inadequately evaluated by mental health providers prior to surgery. The Bariatric Surgery Program team considered the patient’s complex mental health history prior to approving the patient for surgery. The OIG substantiated that the Managing Overweight and/or Obesity for Veterans Everywhere coordinator overstated the patient’s mental health treatment and did not correct the documentation error after discovering it. Concerns were noted regarding the lack of a checklist and the use of informal communication instead of documenting interdisciplinary team discussions. The OIG concluded that an improved process could diminish the risk of an incomplete preoperative evaluation for future patients. The patient successfully underwent bariatric surgery in 2019. The OIG did not substantiate that the patient was insufficiently monitored following surgery. The patient received monitoring for medication, weight loss, and mental health symptoms. Approximately three months after surgery, the patient was seen in the Emergency Department and denied thoughts of self-harm in the previous two weeks. The patient completed suicide five days after the Emergency Department visit. The OIG made six recommendations to the Facility Director related to developing a facility policy for bariatric surgery; ensuring bariatric patients receive all preoperative medical and mental health evaluations; reviewing, correcting, and educating staff on documentation errors; documenting preoperative bariatric interdisciplinary team discussions; and reviewing the Bariatric Surgery Program.