Healthcare Inspection – Oversight Review, Unauthorized Practice of Medicine at a VA Medical Center

The OIG conducted an oversight inspection to determine the validity of allegations of the unauthorized practice of medicine. A complainant alleged that a non-physician staff (subject staff) at a VA Medical Center (the facility) Emergency Department (ED) engaged in the unauthorized practice of medicine by representing himself as a doctor, and that the ED nurse manager was aware of this behavior but did not take action to correct it. The complainant also alleged that the subject staff intubated a patient during an emergency resuscitation causing the patient’s death and that, in another instance, the subject staff pronounced a patient dead. The facility conducted an internal investigation and took corrective actions. The investigation found that the subject staff acted outside the scope of his duties by responding to and participating in a “code blue” event. The facility did not find that the subject staff engaged in the unauthorized practice of medicine. We reviewed all documents produced during the facility’s investigation, pertinent medical records, and other administrative records, and interviewed facility staff. We concurred with the findings of the facility and found the corrective actions to be appropriate. We made no recommendations. The Veterans Integrated Service Network and facility Directors concurred with the report.