Allegations against VA for failing to follow a consultation process – Chillicothe Gazette

CHILLICOTHE The U.S. Department of Veterans Affairs reported that the Chillicothe VA is being reviewed after allegations thatan urgent care provider failed to follow a consultation process, resulting in undocumented patient care.

In a 19-page report released on May 12, the VA Office of Inspector General (OIG) outlines the providersending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic in 202. The patient returned a week later with a T12 burst fracture and rib fractures.

The OIG found that an urgent care provider verbally referred the 87-year-old patient for pain management and not for chiropractic care. However, the OIG found that the urgent care provider did not enter a CAM consult until eight days after seeing the patient.

Veterans Health Administration (VHA) and facility policies require that the sending provider enters a consult, and the receiving provider links the visit note directly to the consult. For a STAT (or a same-day) consult, the sending provider must also contact the receiving provider to discuss the patients case.

Due to this delay, the chiropractor and clinical massage therapist failed to review the consult prior to seeing the patient. Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation resulting in the failure to document care provided within the medical record.

The patient returned to the Urgent Care Center eight days later where a computerized tomography scan showed an acute burst fracture and acute rib fractures. Because of the lack of documentation and provider recall, the OIG could not conclusively determine the relationship between the actions taken by the chiropractor and clinical massage therapist and the patients bone fractures.

The OIG believes that the patients care coordination would have improved for subsequent facility visits by the patient had the urgent care provider entered the consult on the day of the visit,and chiropractor 1and the clinical massage therapist documented the care provided within the patients electronic health record (EHR.)

The OIG conducted a virtual site visit, interviewed several related parties including the complainant, facility leaders and staff, reviewed the patients' EHRs and more to investigate the allegation.

The OIG made two recommendations to the CVAMC facility director:

The OIG conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio. The other nine allegations were"unsupported and lacked merit."

Megan Becker is a reporter for the Chillicothe Gazette. Call her at 740-349-1106, email her at mbecker@gannett.com or follow her on Twitter @BeckerReporting

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Allegations against VA for failing to follow a consultation process - Chillicothe Gazette