Healthcare Inspection—Patient Deaths, Opioid Prescribing Practices, and Consult Management, VA Greater Los Angeles Healthcare System,

OIG conducted a healthcare inspection to evaluate allegations related to patient deaths from drug overdose, inappropriate opioid prescribing practices, and improper consult management at the VA Greater Los Angeles Healthcare System (system), Los Angeles, CA. We did not substantiate that seven patients died from drug overdoses during an 8-month period at the New Directions housing facility. The complainant did not provide names of the seven patients; therefore, we reviewed the electronic health records (EHRs) of six patients who the system reported as having died after moving into New Directions from September 2013 through August 2014. The coroner determined that one of the six patients died from multiple drug intoxication. The drugs listed on the toxicology report had not been ordered by system providers. We did not substantiate that system psychiatrists prescribed inordinate amounts of opioids without oversight. We obtained data showing the system had a lower percentage of patients on larger amounts of opioids than the national average. We substantiated that cardiology consults were canceled or discontinued by non-physician staff members. However, this was an acceptable practice under certain circumstances. Of the 49 consults we reviewed that were canceled or discontinued by non-physician cardiology staff, 5 were inappropriately canceled or discontinued. We did not find documented evidence in the EHRs of patient harm in these five patients; however, patients can be put at increased risk of harm when consults are inappropriately canceled or discontinued. We recommended that the System Director ensure staff conduct a review of canceled or discontinued cardiology consults to determine if patients suffered harm as a result of inappropriate consult closure and confer with the Office of Chief Counsel regarding disclosure as necessary. We also recommended that system staff comply with current Veterans Health Administration policies regarding consult management.