Healthcare Inspection - Delay of Care, Goshen Community Based Outpatient Clinic, Goshen, Indiana

OIG conducted an inspection at the request of Congresswoman Jackie Walorski to assess care provided to a patient at the Goshen Community Based Outpatient Clinic, Goshen, IN, who died of complications related to metastatic lung cancer. We determined that, although this patient’s metastatic disease presentation was not typical, there was a delay in obtaining magnetic resonance imaging (MRI) after computed tomography (CT) results showed left rib involvement, and his quality of life could have been improved through an earlier diagnosis. We could not, however, determine that an earlier diagnosis would have changed his outcome. We also determined the patient and his wife were not aware of VA’s Patient Advocacy Program. We made two recommendations.