The VA OIG confirmed poor health care was linked to the death of one veteran with Hepatitis C at Grand Junction VA Medical Center.
OIG confirmed, “We substantiated the allegation that follow-up care was inadequate and led to further hospitalization.” But allegations that the physician was unqualified to provide specialized care to a Hepatitis C patient was unsubstantiated.
The report continued, “The hepatitis C care provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient’s condition may have contributed to his progressive decline and slower recovery.”
In a “nothing to see here” moment of denial, the System Director at the facility refused to concur with the IG findings.
HEPATITIS C REPORT PARTICULARS
IG investigated three allegations:
- Follow-up care was inadequate leading to further hospitalization.
- A non-qualified physician provided the patient’s Hepatitis C treatment.
- The patient should have been admitted earlier to the hospital based on laboratory results.
The Executive Summary of the investigation findings were as follows:
We substantiated the allegation that follow-up care was inadequate and led to further hospitalization. The Hepatitis C Care Provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient’s condition may have contributed to his progressive decline and slower recovery. Although not part of the original allegations, we also found that contingency plans were not in place to account for reduced availability of the Hepatitis C Care Provider as he started to decrease his hours.
We did not substantiate that a non-qualified physician provided Hepatitis C treatment.
Neither VA policy nor general practice regarding physicians’ credentialing and privileging, ongoing professional practice evaluations, and documentation of education hours require that clinicians have specific evidence of competency to manage Hepatitis C patients.
We did not substantiate that the patient should have been admitted earlier to the hospital based on laboratory results. We found that the patient had an elevated ammonia level that was acknowledged timely and treated with an appropriate medication.
We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability.
This is one of the first IG inspections to be published publicly under the new management of Inspector General Michael Missal.
Let’s hope the partial confirmation of wrongdoing is a sign that the agency watchdog will work fast to repair its tarnished reputation for being little more than a dog with no teeth.
The Hepatitis C issue is a matter of great importance for the veteran community, especially since many of those veterans who are ill were made so by DOD’s negligent use of immunization guns that infected young soldiers during Vietnam.