Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a patient received poor care in the Emergency Department at the Baltimore VA Medical Center (facility) in Maryland, which resulted in an amputation at the patient’s left forearm at a non-VA hospital days later. The OIG identified additional concerns related to the patient’s primary care provider not maintaining the patient’s problem list in the electronic health record and Emergency Department providers’ failure to address the patient’s second chief complaint of knee pain.

The OIG reviewed the care the patient received at the facility’s Emergency Department on two consecutive days in early fall 2021. During the first visit, the patient, with a medical history of poorly controlled type II diabetes, presented to the facility complaining of left hand pain with a ring stuck on the middle finger after sustaining a fall. The following day, the patient returned with left hand pain; redness, swelling, and a superficial open wound to the finger; and knee pain.

The OIG substantiated the patient received poor Emergency Department care during the second visit when a physician assistant failed to obtain laboratory studies for a patient with diabetes and a hand infection, to complete a comprehensive clinical assessment of the patient, and to document a clinical consultation with an attending physician. Additionally, the overseeing attending failed to identify concerns with the physician assistant’s documented care of the patient. The OIG determined these failures may have contributed to the patient’s amputation. An institutional disclosure was conducted, which included a plan for staff training.

The OIG made four recommendations to the Facility Director related to ensuring Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints, evaluation of clinical consultation processes, staff training, and maintaining problem lists.