Report Summary

Title: Deficiencies in a Patient’s Lung Cancer Screening, Renal Nodule Follow-Up, and Prostate Cancer Surveillance at the VA Southern Nevada Healthcare System in Las Vegas
Report Number: 21-01038-49 Download
Report
Issue Date: 12/16/2021
City/State: Las Vegas, NV
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted
Summary:

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to assess an allegation that the facility failed to diagnose and treat a patient’s cancer. The OIG identified concerns about potential deficiencies in lung cancer screening, prostate cancer surveillance, consult delay, documentation, and the facility’s response to family complaints.

The OIG substantiated that providers failed to make a cancer diagnosis and treat the patient’s cancer. Providers did not take steps that would have allowed them to make a diagnosis, including ordering screening tests. In fall 2020, the patient was found to have left lung primary lung cancer with metastasis to brain, liver, and other areas. The patient died three weeks later.

The patient had known lung cancer risk factors that warranted annual screening. The OIG did not find evidence beyond 2013 that pulmonology staff followed up, or that after 2017, primary care providers ensured completion of annual screening. Additionally, the OIG determined that primary care providers did not follow up after a radiology finding that a renal nodule had increased in size. The OIG found that after summer 2016, the patient did not have annual testing completed to check for prostate cancer recurrence. The OIG determined that one primary care provider delayed ordering an oncology consult for 25 days, copied and pasted documentation, and did not document an assessment of the patient’s lung nodules, as required. The OIG found that facility staff documented resolution of a family member’s complaint despite not contacting the family.

The OIG made five recommendations to the Facility Director related to evaluation of lung cancer screening and follow-up care; follow-up for abnormal radiology findings; surveillance for patients who have undergone prostatectomy; copy and paste practices and documentation; and review of complaint reporting and responding.