Review of a Patient’s Care in the Intensive Care Unit at the Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina

Report Information

Issue Date
Report Number
25-03401-257
VISN
2
State
South Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection of the Wm. Jennings Bryan Dorn VA Medical Center to address concerns about nursing practices, patient care quality, and intensive care unit provider staffing. 

A patient in their seventies underwent a right carotid endarterectomy and was monitored overnight. The next morning, the vascular surgeon noted new left-sided weakness and requested a routine neurology consult. Imaging confirmed an acute ischemic stroke and the patient required a thrombectomy, a service not available at the facility. The inspection revealed the patient experienced delays in imaging, neurology consultation, and transfer, stemming from failures to follow rapid stroke evaluation protocols required by VHA and recommended by the American Heart Association and American Stroke Association. Other vulnerabilities included unclear stroke response processes, ineffective integration of TeleCritical Care for surgical intensive care unit patients, and inconsistent nursing documentation.

Due to the severity of patient safety risks, the OIG issued a preliminary advisory memorandum on October 8, 2025. This report updates those findings. 

The inspection also identified intensive care unit coverage gaps were filled by staff without current critical care privileges and contracted physicians sometimes lacked electronic health record access. Although no direct harm was linked to these issues, they increased patient risk. Additionally, facility reviews failed to escalate system concerns, involve needed expertise, or trigger a root cause analysis, reflecting oversight weaknesses and impacting emergency care reliability. 

The OIG made seven recommendations to improve critical care access, stroke response procedures, provider roles and privileges, electronic health record access, and case review.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2026

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.