Healthcare Inspection Alleged Improper Care and Prescribing Practices for a Veteran, Tyler VA Primary Care Clinic, Tyler, Texas

The VA Office of Inspector General Office of Healthcare Inspections conducted an evaluation to determine the validity of allegations regarding inadequate medical and mental health care for a patient at the Tyler VA Primary Care Clinic. The complainant further alleged that the patient had dementia and facility providers disregarded her concerns. We substantiated the allegation that facility providers improperly prescribed opioids and alprazolam to the patient. Specifically, we identified the following deficiencies in prescribing practices: (a) inconsistent documentation of pain assessments, (b) absence of a written opioid treatment agreement or urine drug tests, (c) no consideration of non-pharmalogical approaches for pain management, and (d) absence of evaluations of opioid therapy effectiveness. However, we could neither substantiate nor refute the allegation that prescribing practices contributed to his overdose and death. We found no evidence to support the allegation that the patient had dementia or otherwise lacked decision-making capacity. We recommended that the System Director ensures that providers document pain assessments for patients on opioid therapy and monitor and evaluate these patients in accordance with VHA policies. The VISN and System Directors concurred with our recommendation and provided an acceptable action plan.