Clinically Appropriate Anemia Care and Timing of a Colonoscopy Procedure for a Patient at the VA Caribbean Healthcare System in San Juan, Puerto Rico

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the facility to assess concerns about the diagnosis and treatment of anemia and coordination of a colonoscopy for a patient who subsequently died. The patient had iron-deficiency anemia. The OIG found the primary care provider evaluated and effectively treated the anemia with iron supplements. In 2017, the patient developed a blood clot, which required anticoagulant treatment. In 2018, the patient developed an abnormal heart rhythm and remained on an anticoagulant. The OIG determined that the anticoagulant was managed appropriately and did not clinically affect the patient’s anemia. Late 2020, the patient was admitted to the facility with rectal bleeding and weakness. The patient received a blood transfusion and gastroenterology evaluation. The patient had no further symptoms and was discharged. An outpatient colonoscopy was scheduled. One day later, the patient was readmitted for dizziness. Laboratory testing indicated possible heart muscle damage. Cardiology staff recommended an anemia workup and blood transfusions as needed. The hospitalist discontinued the anticoagulant and requested gastroenterology staff perform the colonoscopy during the admission. The patient had no further symptoms for two days. The morning before a scheduled colonoscopy, the patient experienced chest pain and was transferred to the intensive care unit. Cardiology staff recommended a cardiac catherization but requested gastroenterology staff first determine the cause of and treat the patient’s bleeding. Two days later, gastroenterology staff performed the colonoscopy and treated the source of the bleeding. The following day, towards the end of the cardiac catheterization, the patient developed cardiac arrest, and could not be resuscitated. The OIG found the timing of the patient’s colonoscopy to be clinically appropriate. Providers evaluated the patient across two hospital admissions and adjusted the timing of the colonoscopy to meet the patient’s clinical needs.