Healthcare Inspection: Alleged Quality of Care Issues and Communication Lapses Washington DC VA Medical Center, Washington, DC.

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted a review to determine the validity of allegations regarding a patients quality of care and communication between professional staff and a patients family at the Washington DC VA Medical Center. The complainant alleged that treatment of the patients urinary tract infection was delayed; that the facility did not tell the family the patient had a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection; that the patient was released from outpatient care despite the MRSA infection; and that communication with the family about all of the patients conditions was poor. We substantiated that management of the MRSA urinary tract infection was not timely instituted. When the providers were informed that a large quantity of MRSA was detected in the patients urine, and antibiotic susceptibilities were known, no management changes were made. Within 72 hours of the positive MRSA result, the patient was hospitalized with MRSA sepsis. We found that the facility did not conduct a Quality Review for the outpatient MRSA management issue. We substantiated that the patient and family were not timely notified of the patients MRSA infection while he was an outpatient. However, following admission to the hospital several days later, the patient and family were informed of the MRSA infection. We did not substantiate the allegation that the facility lacked professionalism in relating to the patients family. The nursing staff and physicians we interviewed stated they explained the patients clinical course to the family throughout the hospitalization. There were no formal complaints made to the patient advocate or the leadership team alleging poor communication while the patient was hospitalized.