At the insistence of Rep. Jeff Miller, and prompted by over 1600 complaints of Veterans waiting over a year and half or longer for primary care followup appointments at the Carl T. Hayden VA Medical Center located in Phoenix, Arizona, the VA’s Office of Inspector General (OIG)promptly scheduled and performed a CAP Review. The purpose of the review was also to evaluate selected health care facility operations, focusing on patient care quality and the environment of care, and to provide crime awareness briefings. We conducted the review the same day Representative Miller requested it on April 24, 2014. In fact, we just happened to be there following an earlier phone call from our guy at CNN. Thus we’re able to kill two birds with one stone today.
The review covered seven activities. We made no recommendations in the following two activities:
Coordination of Care
As there is no plan in place to notify patients of the correct date of their appointments, coordination of care was put on hold for a suitable cooling off period to make Veterans forget what it was they were complaining about.
Card-operated machines that dispense medications were installed in the hallway adjacent to the pharmacy’s bulletproof glass windows recently. Veterans with MyHealtheVet or access to Ebenefits can access their medications directly without waiting in line. OIG’s Quality Control and Assurance Team (QCAT) found a 38 percent error rate with type/dosage of medications machine-dispensed but the VISN director assures us they are on track to reducing it to less than 5 percent by January 1, 2015.
We made recommendations in the following five activities:
Veterans Dying Waiting for Appointments
We documented forty cases of Veterans dying while waiting for followup care with their Personal Care Physician (PCP)-not the 236 claimed. Due to confusion in scheduling, the deceased Veterans and their spouses were wrongly told to wait until called. This was incorrect advice and resulted in very long wait times that impacted some Veterans permanently. Nurses and frontline stakeholders are scheduled for refresher training in the existing triage protocols to prevent a recurrence of this unfortunate anomaly the week of May 5-9, 2014. Employees were counseled to avoid contact with the media until after training and all the facts are in.
The Existence of Some “Secret List” for Appointments
In spite of numerous rumors of a secret Bat Cave full of appointments hidden from view, VA’s OIG was unable to substantiate this and found no secret entrances in the basement. A thorough search was conducted, however, and we rounded up the usual suspects.
Poor Morale Among Medical Staff
VA’s OIG was unable to substantiate that morale was low. They found no one willing to squeal because they didn’t want to lose their jobs. This, too, was third hand hearsay and never substantiated. When interrogated alone individually, all medical employees evoked smiley faces and said they were honored to be employed by the VHA and helping Vets.
Pressure Ulcer Prevention and Management
A large number of the dead Veterans mentioned above had extensive pressure ulcers (bed sores) indicating poor hygiene and supervision. Supervisors are admonished to continue annotating this information in the records until someone officially declares the Veteran dead.
Accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers. Perform and document daily skin inspections and daily risk scales for patients at risk for or with pressure ulcers. Provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers. Ensure all designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings. Ensure all designated employees receive training on how to identify dead or dying Veterans.
Allegations of _________________
The Interim Veterans Integrated Service Network Director and Facility Director, Sharon Helman, partially agreed with the Combined Assessment Program review findings and recommendations and provided acceptable answers for improvement plans. She still insists there are no secret records and no Veterans died on her watch. Her feelings were that some Veterans engage in vicarious, risky behaviour to include drug abuse, alcoholism and especially prescription drug abuse. To attribute these deaths to VA’s shortcomings is merely a convenience for survivors to hit the VHA up for money. She indicated she’ll fight to keep her recent $ 9,345.00 bonus because she was simply following VHA executive orders (See Appendixes C and D, pages 20–26, for the full text of the Directors’ comments.) We will follow up on the planned actions until they are completed.
Johnny B. Goode, MD
Assistant Inspector General
for Healthcare Inspections