Healthcare Inspection: Alleged Quality of Care and Problems with Services VA Gulf Coast Veterans Health Care System Biloxi, Mississippi.

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted a review at the request of Congressman Jo Bonner to assess allegations concerning a patient's quality of care as well as address problems with services at the VA Gulf Coast Veterans Health Care System (facility), in Biloxi, MS. The complainant alleged that: (1) Emergency department (ED) physicians did not perform a complete medical evaluation during three of four visits. (2) A Mobile Community Based Outpatient Clinic (Mobile CBOC) primary care provider (PCP) did not assess the patient's chronic back pain. (3) A Mobile CBOC PCP did not return family members' telephone calls. (4) Telephone service at the Mobile CBOC was problematic. (5) Durable medical equipment (DME) was not delivered timely. (6) Payment was (erroneously) denied for a non-VA hospital stay. (7) Facility staff had difficulty coordinating the patient's discharge plans. We substantiated that during one of four ED visits, the March 2012 visit, the patient's overall medical evaluation did not meet VHA standards. Although not one of the complainant's allegations, we found the facility did not conduct a peer review of the ED physician's care. We substantiated the allegation that telephone service at the Mobile CBOC was problematic. We substantiated the allegation that payment for a non-VA hospital stay was originally denied; however, during the course of this review, was revisited by the facility and the Veterans Integrated Service Network 16 staff, and a decision was made to pay the non-VA hospital stay. We did not substantiate the allegation that a PCP did not address the patient's chronic back pain at the Mobile CBOC. We did not substantiate the allegation that the patient did not receive timely delivery of the DME. In fact, the facility policy requires patients to pick up their DME, and the patient was timely notified that the DME was available for pick-up. We also did not substantiate the allegation that facility staff had difficulty coordinating the patient's discharge plans. Due to insufficient documentation, we could neither confirm nor refute the allegation that the Mobile CBOC PCP received any telephone calls from the patient's family members during the months of January, February, or March 2012. We recommended that the facility Director ensure that a quality of care review is conducted with specific attention to the deficiencies identified in this report. We also recommended that the facility Director strengthen processes to address patient complaints regarding the automated telephone system at the Mobile CBOC.