Healthcare Inspection Alleged Continuity of Care Issues and Questionable Death Salt Lake City VA Medical Center, Salt Lake City, Utah

The purpose of this inspection was to determine the validity of allegations regarding failure to provide continuity of care for a patient and the questionable death of that patient at the Salt Lake City VA Medical Center, Salt Lake City, Utah. We substantiated that there was a disruption in continuity of care when the patient returned home from the first hospitalization. We did not substantiate that the patient’s death was due to staff incompetence but that it was a rare complication. We recommended that: (1) clinical staff be educated on rural healthcare needs and availability of services, (2) interdisciplinary discharge planning meetings be coordinated for complex patients, (3) a pharmacist’s performance be reviewed for possible administrative action, (4) clinical staff be educated on adverse event disclosure, and (5) the medical center confer with Regional Counsel regarding informing the patient’s family about their right to file tort and benefit claims.