Deficiencies in Oversight and Leadership Response to Optometry Concerns at the Cheyenne VA Medical Center in Wyoming

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review VISN and facility leaders’ response to allegations that an optometrist was not practicing to the standard of care at the Cheyenne VA Medical Center (facility) in Wyoming. In a response to an OIG request for review, VISN and facility leaders substantiated that the optometrist failed to diagnose patients and delayed testing for 15 of 16 identified patients. The response, however, lacked a plan to review the care of other patients who may have been adversely affected. The OIG identified deficiencies with the facility leaders’ response to the quality of care concerns, state licensing board reporting, and completing proficiency reports for the optometrist.The optometrist was suspended in January 2023 while facility leaders initiated a focused clinical care review of the optometrist’s practice. Although expert reviewers tasked with examining a selection of patient cases expressed significant concerns, and facility leaders’ analysis concluded the optometrist “did not meet the standard of care,” facility leaders did not initiate a review to assess the potential harm to other patients. The optometrist was allowed to return to patient care on a focused professional practice evaluation for cause and showed performance improvement before retiring in July. The OIG found that facility leaders failed to initiate the state licensing board reporting process after the optometrist “failed to meet generally accepted standards of clinical practice” due to a lack of understanding of reporting requirements. The OIG also found the optometrist’s supervisors failed to complete annual proficiency reports in 2021 and 2023 due to an oversight and inexperience by supervisors. The optometry supervisors also failed to address deficiencies identified in other completed proficiency reports. The OIG made recommendations for a comprehensive review of the optometrist’s care, state licensing board reporting, and completing the proficiency process.