Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

Report Information

Issue Date
Report Number
22-02113-75
VISN
21
State
Nevada
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Community Care
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
5
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 Southern Nevada Healthcare System (facility) to assess allegations that facility staff delayed ordering medications following a patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.

The OIG found a community care nurse provided inadequate care coordination, including delayed and omitted clinical documentation. The OIG determined this limited primary care staff's ability to provide care in advance of and after discharge from the community hospital.

Primary care staff care coordination process deficiencies contributed to a delay in the patient’s discharge medications. Primary care staff failed to provide health education to the patient about how to obtain the prescribed medications and did not provide same day access to address a lapse in cardiac medication. Additionally, the primary care provider failed to order the patient’s discharge medications.

The OIG determined that a VISN physician lacked critical clinical information, did not conduct a complete medication reconciliation, and lacked knowledge of the process to order the patient’s anticoagulant medication, contributing to the delay in ordering medication.

The OIG found primary care staff failed to notify suicide prevention staff of the patient’s death by suicide and failed to complete a suicide behavior overdose report immediately upon notification. Further a former suicide prevention program manager failed to timely complete the behavioral health autopsy and a family interview tool contact form.

The OIG made one recommendation to the VISN Director to review the patient’s care and take actions as warranted and four recommendations to the Facility Director related to community care coordination, primary care, actions required following a patient death by suicide, and to take actions as warranted.
 

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 North Las Vegas VA Medical Center Director reviews the community care coordination program, identifies deficiencies, and takes actions as warranted to ensure compliance with the Veterans Health Administration Field Guidebook, including training and completion of all care coordination responsibilities for patients discharged from a community hospital stay paid for by the VA.

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

The North Las Vegas VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the primary care processes, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including response time to patients’ scheduling requests and availability of same-day access for face-to-face and telephone encounters.

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

The Sierra Pacific Network Director in conjunction with the Chief Medical Officer continues the review of the complete course of care provided by the Veterans Integrated Service Network physician for the patient, including the delivery of anticoagulants, and ability to access scanned documents in the electronic health record, and takes actions as warranted.

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

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief and the Primary Care Service chief, review the suicide prevention training program to ensure compliance with Veterans Health Administration policies, including reporting requirements following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.

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

The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief, reviews the suicide prevention coordinators’ compliance with Veterans Health Administration policies, including actions required to complete a behavioral health autopsy and family interview tool contact form following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.