Healthcare Inspection Quality of Care Issues Louis A. Johnson VA Medical Center Clarksburg, West Virginia

The purpose of this review was to determine the validity of allegations of poor communication between the surgeon and the patient/family, delay in dialysis treatment, improper medical record documentation, failure to provide requested medical records, inappropriate use of restraints and continued medication despite evidence of adverse reaction. We concluded that there were deficiencies in this patient’s care that warranted consideration of institutional disclosure to the family. We did not substantiate the complainant’s allegation that surgical residents performed surgery without the family’s knowledge. We substantiated the allegation that dialysis was delayed; however, the medical center now provides in-house dialysis, and a nephrologist is on call at all times. We substantiated the allegation that some of the patient’s medical care was improperly documented. The medical record did not support statements made in an addendum to the discharge summary. We did not substantiate the allegation that a late entry into the electronic medical record was not marked as such, since all entries are automatically timed and dated. We did not substantiate the allegations that: complete medical records were not provided as requested, restraints were improperly used, and a medication was not discontinued despite a possible adverse reaction. Managers concurred with our recommendation to review this case with Regional Counsel to determine whether disclosure was managed appropriately.