Facility Leaders Provided Oversight of a Physician in Fellowship Training at VA Sierra Nevada Health Care System in Reno

The VA Office of Inspector General (OIG) conducted an inspection to assess the oversight and performance of a physician in fellowship training (subject physician) at the VA Sierra Nevada Health Care System in Reno (facility).In early 2021, Canadian authorities arrested the subject physician for the alleged murder of a patient. The subject physician participated in a University of Nevada, Reno (UNR) affiliated geriatric fellowship from fall 2018 through fall 2019, providing care to patients at the facility. The OIG initiated an inspection to review the subject physician’s patient care, the facility’s oversight of the subject physician, and assess VA leaders’ response to the reported allegations.The OIG identified 105 patients that the subject physician provided care to, 17 of whom died. The OIG reviewed the 17 deaths, finding no deficiencies in the quality of care provided by the subject physician, and no patients died from events outside the naturally expected clinical course. The OIG noted an acceptable level of patient care management by the subject physician and found no statistically significant relationship between the subject physician’s rotations and patient deaths.The facility staff and leaders, in conjunction with UNR, onboarded the subject physician per Veterans Health Administration (VHA) requirements. The subject physician’s supervision and evaluation during the fellowship met performance standards and VHA requirements.The OIG determined that facility leaders initiated an issue brief and conducted an electronic health record review of the patients the subject physician treated. However, the Veterans Integrated Service Network (VISN)-led review only included two patient deaths. Based on the criminal allegations, the OIG requested a review focused on the subject physician’s care provided prior to relevant patients’ deaths. The VISN completed the review of an additional seven patients, noting no clinical deficits in care or contribution to patient deaths.The OIG made no recommendations.