Healthcare Inspection –Alleged Quality of Care and Responsiveness Issues, VA Caribbean Healthcare System, San Juan, Puerto Rico

OIG reviewed allegations regarding quality of care issues and management responsiveness at the VA Caribbean Healthcare System, San Juan, PR. We did not substantiate that improper technique during a cystoscopy caused an infection. We could neither confirm nor refute that the resident who performed the procedure ignored the patient’s complaints of pain. We did not substantiate that management was unresponsive to the patient’s concerns. While not one of the complainant’s allegations, we found that the informed consent process was not completed according to policy regarding the change in practitioner prior to the procedure. We recommended that the System Director implement measures to ensure that the informed consent process complies with VHA requirements. The Veterans Integrated Service Network and System Directors agreed with the findings and recommendation and provided acceptable improvement plans.