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Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio

Report Information

Issue Date
Report Number
21-03525-148
VISN
10
State
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio. One allegation involved an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned a week later with a T12 burst fracture and rib fractures. The OIG found that an urgent care provider verbally referred a patient for pain management and not for chiropractic care. However, the OIG found that the urgent care provider did not enter a CAM consult until eight days after seeing the patient. Due to this delay, the chiropractor and clinical massage therapist failed to review the consult prior to seeing the patient. Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation resulting in the failure to document care provided within the medical record. The patient returned to the Urgent Care Center eight days later where a computerized tomography scan showed an acute burst fracture and acute rib fractures. Because of the lack of documentation and provider recall, the OIG could not conclusively determine the relationship between the actions taken by the chiropractor and clinical massage therapist and the patient’s bone fractures. The OIG found the nine additional allegations to be unsupported and lacked merit. The OIG made two recommendations to the Facility Director related to education of providers, chiropractors, and clinical massage therapists on the use of consults and timely documentation, and conducting an internal review of the CAM program processes related to patient care, reviewing consults, scheduling appointments, checking-in patients, and documentation.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chillicothe VA Medical Center Director ensures urgent care providers, chiropractors, and clinical massage therapists are educated on consult processes and procedures and the requirement of timely documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chillicothe VA Medical Center Director conducts an internal review of the Complementary and Alternative Medicine Program processes related to patient care including receiving and reviewing consults, scheduling appointments, checking-in patients for care, and documentation.