Where is 10% a passing grade?
If you answered the Fayetteville VA Medical Center you are correct!
The director of the Fayetteville Veterans Affairs Medical Center took exception Tuesday with a federal audit that said the VA failed to follow up on patients released from the hospital who were considered a high suicide risk.
Under Veterans Health Administration regulations, the VA keeps a list of those patients and is supposed to follow up with them every week for a month.
In a sampling of 10 patients from the list, the audit found that the VA failed to check up on nine of the 10 after the second week.
“Is it a failure? I wouldn’t call it a failure,” VA Director Elizabeth Goolsby said.
The VA OIG’ report dated December 10, 2012, report which identified this problem, also contained some other reports about neglligence at this VA hospital:
Cleanliness. The JC requires that areas used by patients are clean. In the ED, in the specialty clinics, and on the inpatient units, we found dirty exam rooms, restrooms, and supply rooms.
Positive CRC Screening Test Result Notification. VHA requires that patients receive notification of CRC screening test results within 14 days of the laboratory receipt date for fecal occult blood tests or the test date for sigmoidoscopy or double contrast barium enema and that clinicians document notification.3 Seven patients’ EHRs did not contain documented evidence of timely notification.
Follow-Up in Response to Positive CRC Screening Test. For any positive CRC screening test, VHA requires responsible clinicians to either document a follow-up plan or document that no follow-up is indicated within 14 days of the screening test.4 Six patients did not have a documented follow-up plan within the required timeframe.
Diagnostic Testing Timeliness. VHA requires that patients receive diagnostic testing within 60 days of positive CRC screening test results unless contraindicated.5 Five of the 20 patients who had positive screening test results had not received diagnostic testing as of September 13, 2012. The following are the reasons patients did not receive diagnostic testing:
The facility did not initiate two gastrointestinal consults.
The facility did not initiate fee-basis care.
Discharge Medications. The JC’s National Patient Safety Goals require the safe use of medications and stress the importance of maintaining and communicating accurate patient medication information. In two EHRs, medications ordered at discharge did not match those listed in patient discharge instructions.
Follow-Up Appointments. VHA requires that discharge instructions include recommendations regarding the initial follow-up appointment.6 Although provider discharge instructions requested specific follow-up appointment timeframes, five appointments were not scheduled as requested.
Discharge Summary. VHA requires that discharge summaries contain certain elements, such as discharge medications.7 None of the discharge summaries included discharge medications.
Outpatient Follow-Up. VHA requires that all patients discharged from inpatient MH receive outpatient follow-up from a MH provider within 7 days of discharge and that if this contact is by telephone, an in-person or telemental health evaluation must occur within 14 days of discharge.8 Six of the 20 patients who were not on the high risk for suicide list did not receive outpatient MH follow-up within 7 days of discharge nor did they receive an in-person or telemental health appointment within 14 days of discharge. The facility made multiple attempts to contact five of those six patients. Additionally, 2 patients who were contacted by telephone within 7 days of discharge did not have an in-person or telemental health evaluation within 14 days.
Follow-Up for High Risk for Suicide Patients. VHA requires that patients discharged from inpatient MH who are on the high risk for suicide list be evaluated at least weekly during the first 30 days after discharge.9 Nine of the 10 patients who were on the high risk for suicide list did not receive MH follow-up during the last 2 weeks of the 30-day timeframe. MH managers told us that the Suicide Prevention Coordinator position had been vacant until recently. Other MH staff members had rotated responsibility for suicide prevention activities in the interim.
Contact Attempts. VHA requires MH employees to document efforts to follow up with patients who do not keep scheduled MH appointments.10 For two of the nine patients who failed to keep their scheduled MH appointments, we did not find documentation of follow-up attempts.
Since this is the same VA that the VA’s OIG confirmed medical malpractice at earlier in 2012, maybe the Fayetteville VA just sets a very low bar for what is generally accepted as the standard of care, if only 10% right is not a failure, maybe we should accept 0% right, by closing this facility and atleast save some money?
We substantiated that the patient did not receive an accurate diagnosis during his ED visit in mid-June 2011. An ED physician did not complete a comprehensive evaluation and was unaware that the patient had a low sodium level and was being treated with antibiotics for a surgical site infection. The medical center conducted quality of care reviews, but those reviews did not address the deficiencies in this report.
The ED physician failed to review recent and readily available medical records or ask the patient about current medications. The physician had a history of performance deficiencies in these areas, but we found no evidence that deficiencies were addressed or corrective actions taken. Further, the Service Chief and the Professional Standards Board did not follow policy when they renewed the physician’s clinical privileges.
We could not confirm or refute the allegation that the ED physician was rude during the patient’s ED visit.
We recommended that the Medical Center Director ensure actions are taken to improve this provider’s medication reconciliation practices, processes for renewal of clinical privileges comply with Veterans Health Administration guidelines, and a quality of care review is conducted with specific attention to the deficiencies identified in this report.