Alleged Continuity of Care Issues and Questionable Death, Salt Lake City VAMC, Salt Lake City, UT
Full report here:
Executive Summary
The purpose of this review was to determine the validity of allegations regarding failureto provide continuity of care for a patient and the questionable death of that patient at the Salt Lake City VA Medical Center (the medical center), Salt Lake City, Utah. A complainant stated that medical center staff did not provide necessary home care to a laryngeal cancer patient, following a June 2008 hospitalization. The complainant specifically alleged that the medical center did not provide promised tube feeding, pain medications, medical supplies, and a home health nurse to assist him when he arrived at his rural home. The complainant also alleged that the patient was not aware his laryngeal
cancer had spread to lymph nodes and would not have consented to extensive throat and neck surgery had he been informed. The complainant further alleged that the clinician who performed a bone marrow biopsy during that hospitalization was incompetent because an artery was “hit” during the procedure, causing severe bleeding and death.
We substantiated that there was a disruption in the continuity of care following the patient’s discharge from the medical center. Although a physician wrote appropriate orders before discharge, they were not carried through and the patient did not receive nutritional supplements, medications, medical supplies, or home health services upon his return home. Efforts were made to arrange this complex discharge but it was fragmented and not coordinated among all involved disciplines. It is especially imperative that
proper discharge planning occur prior to return home to rural settings.
We did not substantiate that the medical center failed to fully inform the patient prior to the July surgical procedure. Records indicate that the patient was aware that his cancer had spread and discussed the surgery with his family prior to the procedure.
We did not substantiate staff incompetence related to the bone marrow biopsy (the biopsy). We determined the physician who performed the biopsy had completed all the requirements necessary to perform the procedure independently and did not deviate from standard of practice. The patient experienced a rare complication that does not correlate
with clinician experience. However, this adverse event resulted in patient death and the medical center had not disclosed the event to the family.
We recommended that clinical staff be educated on rural health care needs and
availability of services, and that interdisciplinary discharge planning meetings be
coordinated for complex patients. We also recommended that the pharmacist’s
performance be reviewed for possible administrative action. Finally, we recommended that clinical staff be educated on adverse event disclosure, and the medical center needs to confer with Regional Counsel regarding informing the patient’s family about their right to file tort and benefit claims. Veterans Integrated Service Network and Medical Center Directors concurred with our findings and recommendations and offered acceptable corrective action plans.
"The price of freedom is eternal vigilance."
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"The shepherd drives the wolf from the sheep's for which the sheep thanks the shepherd as his liberator, while the wolf denounces him for the same act as the destroyer of liberty. Plainly, the sheep and the wolf are not agreed upon a definition of liberty."- Abraham Lincoln
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-- John Adams (Address to the Military, 11 October 1798)
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