Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation of abuse and quality of care concerns for a patient at the Fort Harrison VA Medical Center and the Miles City Community Living Center (CLC) in Montana. The OIG identified issues related to a pattern of patient mistreatment in the CLC, care coordination and discharge planning, and facility leaders’ noncompliance with state licensing board requirements.

The OIG substantiated the allegation that a physical therapist and nursing staff forced the patient to participate in physical therapy in the CLC even though the patient objected. During the review, the OIG discovered additional findings related to facility oversight processes including three previous investigations of patient abuse in the CLC. The OIG concluded that leaders’ failures in responding to a pattern of mistreatment and in reviewing and reporting licensed healthcare professionals to state licensing boards may have fostered a culture of mistreatment at the CLC. Additionally, the OIG found that facility leaders did not assess the CLC physician’s performance and competence for treating patients in the CLC as required and determined that failure in care coordination between physicians led to an absence of a suggested follow-up plan for a suspected lung mass in the discharge summary to a state veterans home.

The OIG made one recommendation to the Rocky Mountain Network Director related to the review of facility staff’s actions taken in response to the allegations and concerns related to the identified patient. The OIG made six recommendations to the Facility Director related to ensuring the rights of CLC patients, reviewing the care provided to the patient by the CLC nursing staff and physician and during the patient’s acute care hospitalization, reviewing the screening and admissions process for CLC patients, and complying with the state licensing board reporting policy.