Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque

Report Information

Issue Date
Report Number
24-02059-177
VISN
22
State
New Mexico
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Patient Safety
Major Management Challenges
Benefits for Veterans
Healthcare Services
Leadership and Governance
Recommendations
15
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA New Mexico Healthcare System (facility) to assess allegations and concerns related to the care of a patient who was labeled as ineligible for care and senior leaders’ associated response.

In early 2024, the patient was admitted to the facility and applied for healthcare benefits. The patient inaccurately reported income on the application, and benefits were declined. Social work staff, aware of the inaccuracies, did not ensure information was corrected. Additionally, staff attempted to arrange post-hospital services only available to eligible patients and failed to coordinate follow-up care after discharge.

In spring 2024, the patient returned to the facility, was admitted, and then discharged the same day due to being labeled as ineligible for care. The OIG did not substantiate that a podiatrist was forced to discharge the patient. However, knowledge and communication deficits contributed to the following deficiencies:
•    The emergency department provider did not follow stated practice to transfer or admit the patient. 
•    Staff missed another opportunity to update the patient’s financial information.
•    The podiatrist did not seek Chief of Staff approval to continue care at the facility or transfer the patient to a community hospital.
•    Staff did not provide an adequate discharge plan. Instead, the patient was left alone on a bench to await ambulance transport and did not receive written discharge instructions.
•    The podiatrist did not contact the community hospital to share information.
•    The nurse officer of the day failed to address a nurse’s attempt to escalate concerns.

The OIG found senior leaders did not effectively use root cause analysis processes or apply High Reliability Organization principles to assess the spring 2024 discharge. First-year podiatry residents were not supervised according to Veterans Health Administration policy.

The OIG made 15 recommendations to the Facility Director.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patient’s financial information and documents are not required to verify financial information.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients’ care.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director ensures that inpatient providers are aware of the process to obtain Chief of Staff approval for an ineligible patient to continue care at the facility when clinically indicated.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director ensures that inpatient social workers, providers, transfer coordinators, and nurses are aware that ineligible patients can be transferred from the facility and provides education related to the processes required for approval and facilitation of the transfer.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director educates staff on steps to take if attempts to escalate concerns to their supervisors are not adequately addressed.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director reviews the facility’s root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director makes certain that leaders are aware when assigned as responsible for root cause analysis action items and adhere to action plan due dates.

No. 14
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.

No. 15
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA New Mexico Healthcare System Director monitors the podiatry residency program for compliance with VHA Directive 1400.01 postgraduate year 1 resident supervision requirements.