Quality of Care Concerns and Leaders’ Responses at the Amarillo VA Health Care System in Texas

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to a primary care provider’s delivery of hypertension treatment and post-stroke care, nursing staff communication and documentation, and facility telephone communication processes at the Amarillo VA Healthcare System (system) in Texas. The OIG was unable to determine whether delays in treatment for hypertension and headaches caused the patient’s stroke and did not find primary care-related treatment failures in the weeks leading up to the stroke. However, when the patient presented to the clinic with stroke-like symptoms in early 2021, the provider and clinic nurse failed to ensure the patient received urgent medical attention. The delay in evaluation and treatment may have resulted in a more difficult recovery for the patient. The OIG did not substantiate allegations regarding a failure to order cardiology and neurology consults, that a licensed vocational nurse diagnosed the cause of the patient’s headaches, or that secure messaging was the only way the patient could communicate with the primary care team. The OIG was unable to determine whether nurses’ communications were dismissive and condescending. The OIG identified multiple system leaders’ failure to assess and follow through on the provider’s ongoing quality of care deficits. These failures allowed the provider to continue practicing substandard medicine, and as a result, patients experienced adverse outcomes. The provider has been functioning in an administrative capacity without direct patient care duties since spring 2021. The OIG made one recommendation to the Veterans Integrated Service Network Director to assess system leaders’ actions related to professional practice evaluations, institutional disclosure, and staff training. The OIG made five recommendations to the System Director related to vital sign protocols, clinical practice evaluation of a nurse, respectful communications, critical view alerts and other quality of care reviews, and communication and documentation requirements.