Healthcare Inspection Quality of Care Issues VA Nebraska-Western Iowa Health Care System Omaha, Nebraska And VA Central Iowa Health Care System Des Moines, Iowa

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of allegations regarding the quality of care received by a patient at both the Omaha, Nebraska (system 1) and Des Moines, Iowa (system 2) VA Health Care Systems. The complainant alleged that: While at system 1 a patient: (1) suffered a stroke that was unnoticed by staff, (2) did not receive assistance with activities of daily living (ADLs), (3) did not receive rehabilitative therapy, (4) did not receive a pulmonary treatment, (5) did not receive pain medication timely, and (6) had a delay in receiving medication by mail. While at system 2 the patient did not receive assistance with his ADLs, speech therapy, and discharge planning. We substantiated that the patient did not receive one pulmonary treatment, medication by mail timely, and was not reassessed for pain medication effectiveness. We recommended that the System 1 Director ensure that clinicians review the delay in medication by mail and ensure that pain assessments and reassessments are done according to policy.