Deficiencies in the Care of a Patient with Gastrointestinal Symptoms at the Eastern Oklahoma Health Care System in Muskogee

The VA Office of Inspector General (OIG) conducted a healthcare inspection of an allegation related to a patient who sought help with gastrointestinal symptoms at the Eastern Oklahoma VA Health Care System in Muskogee (facility) three times in 2020 and was allegedly sent away. The patient went to a non-VA hospital and was diagnosed with colorectal cancer in early 2021. The OIG did not substantiate that the patient was sent away three times. The OIG identified concerns related to the patient’s fecal immunochemical test (FIT), an Emergency Department physician’s patient assessment, and facility leaders’ response to the patient’s complaints and multiple Emergency Department physician complaints. The electronic health record contained no documented evidence that the FIT was mailed to or discussed with the patient, even when not returned. The Emergency Department physician did not adequately assess the patient by failing to perform a digital rectal examination when the patient’s clinical presentation included having blood in the stool. Facility staff did not adequately review and respond to the patient’s complaints. A primary care leader did not fully resolve complaints related to providers’ patient interactions and care. The patient advocate failed to address a complaint, document the involved providers, or contact the patient. The OIG found facility leaders initiated peer reviews and provided an institutional disclosure to the patient but identified leaders’ inadequate response to complaints about the Emergency Department physician. Beyond reporting and intermittent discussions with the provider, leaders took no further actions to address the physician’s performance concerns. The OIG made four recommendations to the Facility Director to ensure FITs are tracked, evaluate Emergency Department providers’ processes for examinations when patients present with gastrointestinal symptoms with bleeding, ensure thorough reviews and documentation of patient complaints, and ensure leaders monitor complaints related to the Emergency Department physician.