Healthcare Inspection – Alleged Quality of Care and Administrative Issues, Sheridan VA Medical Center, Sheridan, Wyoming

OIG conducted an evaluation to determine the validity of allegations regarding poor quality of care and administrative issues at the Sheridan VA Medical Center, Sheridan, WY. We did not substantiate that the patient’s care for his lung condition resulted in a terminal illness and permanent confinement in a hospice unit or that the level of care caused the patient’s clinical deterioration, subsequent non-VA hospitalization, and need for prolonged inpatient care and rehabilitation. We substantiated that medical record documentation did not consistently include current clinical assessment of the respiratory problem, lung examinations, or follow-up information regarding the patient’s response to antibiotic therapy. We substantiated that the treatment for the patient’s elbow bursa infection was inadequate and the physician’s documentation did not meet VHA standards. We did not substantiate that facility managers responded unprofessionally to the patient’s or brother’s concerns. We found that the cessation of prednisone did not meet the accepted practice in the management of long term, daily corticosteroid therapy and the facility did not conduct Peer Review for the lung and elbow issues. OIG made three recommendations: (1) consult with Regional Counsel regarding possible institutional disclosure, (2) implement procedures to ensure facility staff comply with VHA policies on peer review and physician privileging, and (3) monitor physicians’ documentation to ensure compliance with VHA policies. The VISN and facility directors concurred with our recommendations and provided acceptable action plans.