Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, IN

The OIG evaluated allegations that staff at the Richard L. Roudebush VA Medical Center (facility) provided inadequate alcohol withdrawal management in the Emergency Department for a patient who died approximately two days after discharge, inadequately responded to the patient’s urgent care needs, and failed to provide posttraumatic stress disorder (PTSD) care. During the inspection, the OIG also identified concerns related to discharge care coordination, leaders’ failure to consider an institutional disclosure, and adequacy of primary care assessments and documentation regarding the patient’s alcohol use and safe transport. The OIG substantiated that Emergency Department staff mismanaged the alcohol withdrawal care of the patient, and that a medical support assistant inadequately responded to the patient’s report of “bad” withdrawal symptoms and lack of transportation to the Emergency Department. It was not substantiated that facility staff failed to provide PTSD care. Facility leaders had not established procedures for care coordination of patients discharged from the Emergency Department. The extent of family member involvement in the patient’s discharge planning could not be determined because of the absence of documentation and conflicting reports. Although the OIG determined an institutional disclosure should have been considered following the patient’s adverse clinical outcome, facility leaders told the OIG that it was not considered because internal reviews did not warrant that action. A nurse practitioner failed to thoroughly assess the patient’s substance use, schedule follow-up, and discuss immediate safety concerns. The OIG made seven recommendations to the Facility Director related to a review of the patient’s care, evaluation of the Emergency Department alcohol withdrawal management protocol, consideration of written Emergency Department discharge planning and care coordination guidance, consideration of institutional disclosure, establishment of administrative staff protocol for urgent care needs, and primary care procedures for management of intoxicated patients.