Surrogate Decision-Maker, Clinical, and Patient Rights Deficiencies at the Robley Rex VA Medical Center in Louisville, Kentucky

The VA Office of Inspector General (OIG) assessed an allegation that providers permitted an individual with no legal authority to make medical decisions on behalf of a patient. The patient had a three-week medical and mental health hospitalization with repeated episodes of confusion, agitation, and combative behavior. The patient was transferred to hospice care and died five days later. The OIG substantiated the patient’s neighbor had no legal authority but made medical decisions. The OIG noted clinical and patient rights deficiencies and reviewed facility leaders’ evaluation of the deficiencies in the patient’s care. Facility staff did not take the required appropriate steps to identify and confirm the eligibility of this surrogate. Staff searched the patient’s belongings and records, but they did not review other VA records. Three days after the patient’s death, administrative staff located a family member from VA benefits records. The OIG determined that records did not contain sufficient documentation of physicians’ clinical assessments to support diagnoses and treatment decisions. Clinical communication and collaboration were inconsistent, insufficient, and negatively impacted the patient’s continuity and quality of care. Providers did not consistently document medication monitoring and oversight activities to ensure safe patient care. The OIG concluded the patient’s transfer to hospice was completed without fully pursuing other diagnoses and treatment options and staff did not ensure the patient’s rights were upheld regarding involuntary admission and behavioral restraints. Facility leaders did not complete a thorough quality of care review to understand the reasons for the patient’s atypical hospital course and outcome. The OIG made 15 recommendations to the Facility Director related to the patient’s decisional capacity, surrogate identification, medical assessments, medication management, and hospice admission. Other areas of focus included patient rights, quality management processes, and institutional disclosure.