Complications Associated with Phototherapy at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to the care provided to a patient who was mistakenly treated with phototherapy for bed bugs and developed complications. Two days after receiving the phototherapy treatment, the patient was hospitalized for first degree (outer layer of the skin) and second degree (deeper layers of the skin) burns. Phototherapy is ordered by a dermatologist after diagnosis of a skin condition that would be responsive to treatment. Phototherapy is not indicated for the treatment of patients with bed bugs. A dermatology clinic registered nurse (RN) provided phototherapy to the patient for the treatment of bedbugs without a provider assessment and order, even though a dermatologist was available for assessment the day of treatment. Facility staff improperly attributed the need for action to its Integrated Pest Management policy that guides environmental actions. Despite an appendix to the policy that stated, “there is no specific medical treatment for bed bugs,” facility staff pursued a clinical treatment, phototherapy, for the patient. Facility leaders initiated a fact-finding review. The review’s charge letter was unclear regarding its confidential or non-confidential status. Confidential reviews may not be used as a basis for administrative action. The OIG made two recommendations to the Veterans Integrated Service Network 16 Director related to fact finding reviews conducted at the Gulf Coast Veterans Health Care System. The OIG made five recommendations to the Gulf Coast Veterans Health Care System Director related to dermatology clinic nurse practice requirements, training, and competencies; a review of the Gulf Coast Veterans Health Care System’s policy related to environmental actions following identification of bed bugs; necessary training related to the policy; and completion of Gulf Coast Veterans Health Care System’s actions recommended by an internal review.