The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senator Joe Manchin to review the postoperative care of a patient (Patient) who had vascular surgery at the Martinsburg VA Medical Center (Facility), West Virginia. In general, the OIG found the Patient’s immediate postoperative care was proper. However, the OIG had concerns with the Patient’s management at the Community Based Outpatient Clinic (CBOC) 10 days after the procedure when the Patient presented with signs and symptoms of a known vascular procedure complication. After an endovascular aneurism repair (EVAR), the Patient’s clinical condition was consistent with cholesterol embolization syndrome which has no accepted specific therapy. On EVAR post-operative day (POD) 14, the Patient had amputations of three toes and was noted to have infection in the amputated bone. The OIG could not determine if earlier toe amputations would have prevented the bone infection. On POD 10, after determining the Patient was experiencing a medical emergency, CBOC patient aligned care team staff did not ensure coordination of the Patient’s subsequent care. Staff failed to facilitate a safe transition between the CBOC and a non-VA hospital equipped to treat the Patient. Staff did not communicate relevant information or provide health record information to providers at the non-VA hospital upon learning where the Patient planned to seek emergency treatment. The OIG found deficiencies in Veterans Health Administration policy compliance with the lack of policy or standard operating procedure on the management of health emergencies in the CBOC and inconsistent health record documentation for the Patient. The OIG made three recommendations related to coordination of care, health emergency management, and health record documentation.
Martinsburg, WV
United States
