Alleged Improper Care and Prescribing Practices for a Veteran. Tyler VA Primary Care Clinic Tyler, Texas. Healthcare Inspection

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted an evaluation in response to allegations by a complainant. Allegations included inadequate medical and mental health care, including improper prescribing practices at the Tyler VA Primary Care Clinic in Tyler, TX. The complainant further alleged that the patient had dementia and facility providers disregarded her concerns. We did not substantiate the allegations of inadequate medical and mental health care. We substantiated the allegation that facility providers improperly prescribed opioids and alprazolam to the patient. Specifically, we identified the following deficiencies in prescribing practices: (a) inconsistent documentation of pain assessments, (b) absence of a written opioid treatment agreement or urine drug tests, (c) no consideration of non-pharmalogical approaches for pain management, and (d) absence of evaluations of opioid therapy effectiveness. However, we could neither substantiate nor refute the allegation that prescribing practices contributed to his overdose and death. We found no evidence to support the allegation that the patient had dementia or otherwise lacked decision-making capacity. We did not substantiate the allegation that providers disregarded the complainant's concerns.