Deficiencies in Emergency Care for a Female Veteran at Martinsburg VA Medical Center in West Virginia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the care of a female patient who presented with “near constant” vaginal bleeding to the Martinsburg VA Medical Center (facility) Emergency Department. 

While no deficiencies were found in the care provided by emergency department physicians, the OIG identified multiple deficiencies in nursing care. The OIG also identified failures in leaders’ oversight to ensure deficiencies were sufficiently remediated.

The OIG determined that the emergency department was equipped to perform gynecologic exams. However, the gynecologic cart, which featured hinged foldable footrests used in extension with the emergency department bed, was not utilized by some providers due to concerns of discomfort for patients.

The OIG substantiated delays in the patient’s transfer to a higher level of care, with an avoidable delay by the facility fire department’s ambulance service. Facility fire department leaders attributed the delay to lack of available staff and inability to mandate overtime for transports. However, the OIG determined that the practice of prohibiting mandatory overtime for emergency transports was incongruent with facility policy and facility leaders’ expectations. The OIG also found that facility leaders failed to assess concerns about the transport delay identified during a factfinding. 

The OIG learned that while the facility initiated a formal review to address broader patient transport challenges in May 2023, more than a year later, recommended policy and protocols identified from the review had not yet been approved by facility leaders.

The OIG made 10 recommendations to the Facility Director related to emergency department communication, adherence to Veterans Health Administration and facility policies, review of implemented actions to ensure quality of care concerns are remediated, evaluation of emergency department equipment for gynecologic examinations, review of overtime practices for staff providing emergency transports, and review of transportation concerns.