Failures in Care Coordination and Reviewing a Patient’s Death at the VA Salt Lake City Healthcare System in Utah

The VA Office of Inspector General (OIG) conducted an inspection at the VA Salt Lake City Healthcare System (facility) in Utah to assess allegations of lack of care coordination and a delay in a patient receiving an anticoagulant medication, refusal to hire a community-based outpatient clinic (CBOC) pharmacist, delays in relocating the Orem CBOC, and that the Facility Director ordered patients to be bussed to the facility for care. The OIG did not substantiate a lack of care coordination. A non-VA hospital provided the patient with a discharge summary, a prescription and savings card for a one-month supply of medication, education, and a follow-up call. The non-VA hospital also provided the facility with the discharge summary and prescription. The OIG substantiated the patient’s nurse delayed care by not returning the patient’s call for assistance with obtaining the medication, and by not informing the covering provider of the patient’s request and that the patient had been off of the medication for four days. The patient died the following day. The facility conducted an internal review of the patient’s care. The OIG found that the review was incomplete and included inaccurate information and leaders were unable to determine if an institutional disclosure was warranted. The OIG did not substantiate the Chief of Pharmacy refused to hire a CBOC pharmacist, that having a pharmacist would have allowed the patient to obtain the medication, or that the Facility Director ordered patients to be bussed from the Orem CBOC to the facility for care. The OIG substantiated the Orem CBOC relocation was delayed, but the facility developed and implemented a contingency plan to address the delay. The OIG made three recommendations related to a clinical care review of the patient, root cause analysis processes, and determining the need for an institutional disclosure.