Healthcare Inspection - Alleged Mismanagement of Care and Delayed Adverse Event Reporting, Robert J. Dole VA Medical Center Wichita, Kansas

The OIG conducted an inspection to determine the validity of allegations regarding the quality of care at the Salina, KS Community Based Outpatient Clinic (CBOC). We substantiated the allegation that the care of the patient was mismanaged. We are unable to determine and do not assert that a more prompt medical response would have resulted in preventing the patient’s death. We found lack of proper, timely reporting of this death at multiple levels, but could not substantiate that there was an institutional attempt by Salina CBOC or facility staff to “cover-up” the mismanagement of the patient’s care; that the RCA was perfunctory or lacking in sufficiently strong recommendations; and that facility management may have taken adverse action against the individual who reported the incident. We found inadequate triage practices, physician supervision, and physician availability on the day of the events in question; oversight reviews of all the relevant clinicians who were, or should have been, involved in the patient’s care were not performed; and that adversarial staff relationships existed at the CBOC which may have impeded effective staff communication about the patient in this case. Additionally, we found that some issues identified during the RCA were not fully corrected. We made six recommendations.