Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma

The VA Office of Inspector General (OIG) conducted an inspection in response to allegations related to ophthalmology resident supervision and quality of care by an attending ophthalmologist (subject ophthalmologist) at the Oklahoma City VA Health Care System in Oklahoma. The OIG substantiated that the subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case. The ophthalmology residents were unable to reach the subject ophthalmologist when the patient experienced a complication during an eye injection procedure. The residents reached another attending ophthalmologist who examined the patient and assisted the residents. The subject ophthalmologist was assigned to supervise residents in the clinic and did not arrange a hand-off for attending coverage when away from the clinic. The OIG found that a note in the patient’s electronic health record that documented supervision by the subject ophthalmologist was incorrect because the subject ophthalmologist did not directly participate in and was not present during the care of the patient. The subject ophthalmologist used a standard template and acknowledged the note was incorrect due to a failure to read and edit the note before signing it. Aside from the single patient case, the OIG did not identify other failures to supervise residents or inaccurate documentation of resident supervision by the subject ophthalmologist. The subject ophthalmologist, aside from the single patient case, provided and documented proper patient care. A review of 20 patients performed by an external ophthalmologist and the OIG determined the subject ophthalmologist provided acceptable quality of care and appropriate documentation. The OIG made three recommendations to the Facility Director related to documentation of resident supervision and the hand-off process for attending ophthalmologist coverage.