Quality of Care Issues in the Community Living Center and Emergency Department at the Dayton VA Medical Center, Ohio

The OIG initiated an inspection to assess allegations regarding quality of care concerns at the facility with a focus on a patient’s care who transferred from the facility’s Community Living Center to the Emergency Department. The patient died in the Emergency Department. The OIG found delays and deficits in the patient’s care in the Emergency Department. An Emergency Department registered nurse failed to initiate cardiac and oxygen saturation monitoring. Deficiencies were also identified in medical decision making, provision of care, and handoff communication by an Emergency Department physician. The OIG determined that deficits in the physician’s practices were not limited to this case and shared these concerns with facility leaders. The physician was placed on a summary suspension and a management review of the physician’s practice was conducted, resulting in identification of “significant recurrent concerns” with the physician’s management and documentation. The facility’s Clinical Executive Board revoked the physician’s privileges. The physician appealed the decision. The VA Disciplinary Appeals Board overturned the physician’s removal from service; however, the physician subsequently resigned. The OIG identified concerns related to the facility’s quality management processes; the facility established a new standard for initiating management reviews to address those concerns. The OIG did not substantiate that the Emergency Department registered nurse was involved in additional patient deaths or that Emergency Department night-shift staffing was inadequate. Implementation of Emergency Department standing orders was inconsistent, and facility staff incorrectly destroyed a focused professional practice evaluation. Thirteen recommendations were made related to provider training, policy concerning transitions of care, standing orders, monitoring of critically ill patients, peer review training, Peer Review Committee documentation, leaders’ responses to identification of care concerns, Emergency Department supplies, bar code medication administration compliance, and document management procedures.