Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns about a patient with multiple medical problems at the Malcom Randall VA Medical Center (VAMC) in Gainesville, Florida. In this inspection, the OIG identified potential issues related to discharge planning and care coordination for a patient who died 17 days after discharge from a 33-day hospital stay at Malcom Randall VAMC.

The Malcom Randall VAMC’s interdisciplinary team (IDT) failed to develop a discharge plan that adequately ensured patient safety and continuity of care. The Malcom Randall VAMC did not have a discharge planning policy that outlined IDT membership, communication expectations, or roles in discharge planning. The OIG found that the occupational therapy provider did not verbally communicate a new recommendation for a home safety assessment or take action to stop the discharge until the safety concerns were addressed. Additionally, an attending physician failed to review written recommendations for home healthcare services from consultative and ancillary providers before composing the discharge plan for the patient. The social worker, who had significant responsibility for ensuring the adequacy and safety of the patient’s discharge plan, also failed to incorporate recommendations by the occupational therapy provider and failed to discuss and offer home health services to manage the patient’s venous leg ulcer and monitor infection of the right leg. The OIG also found that social workers did not consistently complete thorough and detailed psychosocial assessments that would be pertinent to discharge planning.

The OIG made five recommendations to the Facility Director related to roles and responsibilities of IDT members, communication of changes in patient care recommendations between providers, and a review of the care rendered to the patient by providers involved in discharge planning.