Healthcare Inspection – Quality of Care Issues, West Palm Beach VA Medical Center, West Palm Beach, Florida

OIG conducted an inspection in response to a letter forwarded by Florida Governor Rick Scott. The letter contained multiple allegations about the quality of care at the West Palm Beach VA Medical Center (facility), West Palm Beach, FL. We did not substantiate that events related to patient falls resulting in injury and the deaths of two patients were not reported or investigated. However, we found that the investigation of one of the seven patient falls that we reviewed was not timely. We did not substantiate the allegation that a patient missed a scheduled chemotherapy treatment; however, completion of the patient’s chemotherapy was delayed, and the incident was not reported to the Patient Safety Manager (PSM) as required. We did not substantiate the allegation that a patient was inappropriately given medication during a cardiac arrest or that the patient’s death was not properly reported or investigated; however, we found that the correct progress note was not used resulting in the Risk Manager not initiating the required review. We substantiated the allegation that a patient had the wrong lens implant placed in his eye during cataract surgery because the operative team failed to properly perform the time-out process. The PSM was not notified of the incident immediately, as required, using the Critical Incident Tracking Notification system. We did not substantiate the allegation that facility staff “covered up” or failed to disclose adverse events. We found that local policy for reporting patient incidents and/or safety concerns was not being followed, causing unnecessary delays and missed opportunities for early intervention. Although not an allegation, we found that Quality Management Service has been chronically understaffed. We made four recommendations.