Review Finds Multiple Faults at Nashville, York VA

By Walter F. Roche Jr.

An inspector general's report on U.S. Veterans Affairs facilities in Nashville and York has found multiple serious deficiencies in the care provided to veterans including the failure to adequately review surgical procedures resulting in death.
The report from the VA Office of Inspector General issued Thursday also found that the care provided to severe stroke victims did not meet expected standards primarily due to the complete lack of a stroke management policy.
At York, auditors found, three veterans suffering acute strokes were not considered for transfer to a stroke specialty facility due to the lack of a set policy for doing so.
In the review of surgical procedures, the report states, "Several surgical deaths that occurred from January to June of 2013 had identified problems or opportunities for improvement. There was no evidence that the morbidity and mortality committee reviewed one of those deaths."
Other deficiencies in stroke care included failure to screen 12 of 26 patients in Nashville and five of nine in York for swallowing difficulties before they were fed.
The audit covered fiscal 2013 and the first eight months of 2014 and the findings were not disputed by the VA. The agency also agreed to corrective actions recommended by the inspector general.
The two facilities were praised for the care provided by telephone consultations, but in many other areas deficiencies were noted.
For instance so-called peer reviews of cases over a six month period had not been reported to an oversight panel in 20 of 28 cases. Six focused reviews of physicians' performances had not been reported to the Medical Executive Board, the panel that issues credentials to physicians.
Reviews required in cases where cardio-pulmonary resuscitation was used were not performed and a surgical quality review committee had met only two times over six months.
Minutes of the meetings of the executive board "did not reflect sufficient discussion of corrective action and tracking of events to closure," the audit states.
Electronic medical records both at York and Nashville did not include discharge instructions in nine cases and five patients did not receive "services or items ordered for them within the prescribed time frame."