Healthcare Inspection Alleged Imminent Danger to Patients Southern Arizona VA Health Care System Tucson, Arizona

The Office of the Inspector General received a complaint that alleged unsafe care and imminent danger to patients who receive care at the Primary Care Clinics at the Southern Arizona VA Health Care System in Tucson, Arizona (the facility). The allegations included unsafe triage and handoff of patients from the Emergency Department (ED), inadequate clinical support staff, unsafe patient panel sizes, and other quality of care issues. We did not substantiate that patients in Primary Care (PC) were in imminent danger however we did find that the facility had experienced significant turnover among Primary Care Providers (PCPs) that resulted in reassignment of patients to the remaining PCPs who felt overwhelmed and unsupported by management. Also, there were limited treatment options for patients with chronic pain issues and care was often not coordinated. We substantiated that there was unsafe triage of patients in the ED. ED staff did not always evaluate every patient before discharge as required by policy. Non-urgent patients were sometimes sent for a second screening in PC where they were given appointments to be seen by a provider at a later date. We did not substantiate that patients received narcotic and non-narcotic prescriptions without proper assessment, that clinical staff was inadequate in PC, that consultants were placing orders under the PCP’s name without notification or consent of the provider, or that inadequate number of providers resulted in poor patient follow-up, unsafe patient panel sizes, unassigned patients, and practitioners being forced to work long hours and from home. The VISN and facility Directors agreed with our findings and recommendations. The implementation plans are acceptable, and we will follow up on the planned actions until they are completed.