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Mistreatment and Care Concerns for a Patient at the VA Montana Healthcare System in Miles City and Fort Harrison

Report Information

Issue Date
Report Number
22-01341-43
VISN
19
State
Montana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Patient Safety
Medical Staff Privileging Credentialing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation of abuse and quality of care concerns for a patient at the Fort Harrison VA Medical Center and the Miles City Community Living Center (CLC) in Montana. The OIG identified issues related to a pattern of patient mistreatment in the CLC, care coordination and discharge planning, and facility leaders’ noncompliance with state licensing board requirements. The OIG substantiated the allegation that a physical therapist and nursing staff forced the patient to participate in physical therapy in the CLC even though the patient objected. During the review, the OIG discovered additional findings related to facility oversight processes including three previous investigations of patient abuse in the CLC. The OIG concluded that leaders’ failures in responding to a pattern of mistreatment and in reviewing and reporting licensed healthcare professionals to state licensing boards may have fostered a culture of mistreatment at the CLC. Additionally, the OIG found that facility leaders did not assess the CLC physician’s performance and competence for treating patients in the CLC as required and determined that failure in care coordination between physicians led to an absence of a suggested follow-up plan for a suspected lung mass in the discharge summary to a state veterans home. The OIG made one recommendation to the Rocky Mountain Network Director related to the review of facility staff’s actions taken in response to the allegations and concerns related to the identified patient. The OIG made six recommendations to the Facility Director related to ensuring the rights of CLC patients, reviewing the care provided to the patient by the CLC nursing staff and physician and during the patient’s acute care hospitalization, reviewing the screening and admissions process for CLC patients, and complying with the state licensing board reporting policy.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Montana VA Healthcare System Director reviews the patient’s acute care, including actions to address medical recommendations, and takes actions as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.