Healthcare Inspectors Discuss Issues Related to a Patient's Quality of Care in Ohio's Chillicothe VAMC

In this episode, healthcare inspectors discuss the report Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio.

Show Notes

Related Report:

Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio

The VA 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.

One allegation involved an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned a week later with a T12 burst fracture and rib fractures.

The OIG found that an urgent care provider verbally referred a 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. 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 patient’s bone fractures.

The OIG found the nine additional allegations to be unsupported and lacked merit.

The OIG made two recommendations to the Facility Director related to education of providers, chiropractors, and clinical massage therapists on the use of consults and timely documentation, and conducting an internal review of the CAM program processes related to patient care, reviewing consults, scheduling appointments, checking-in patients, and documentation.

What is Inside Oversight?

Inside Oversight is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode examines in detail some of our more nuanced oversight reporting. To understand the complexities of the topics, we talk with the report authors to gain insight into how the team conducted its work, what it found, and the impact on veterans and the public. Visit the VA OIG website for recently published reports.

Adam Roy:
Hello and welcome back to another episode of Inside Oversight, a podcast of the Veterans Affairs Office of Inspector General.

This is your host, Adam Roy.

In this episode, I’m speaking with Sheena Mesa, a nurse consultant, and Shelby Assad, a health system specialist, within the Office of Healthcare Inspections here at the VA OIG.

We’re going to discuss the report Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio. We published this report in May 2022.

Welcome, Sheena and Shelby. How are you guys doing today?

Sheena Mesa:
I’m doing well, Adam. Thank you.

Shelby Assad:
Yes, thank you so much for having us here today.

Adam Roy:
Good. Let’s start off, Sheena. briefly tell the listener the focus of this report.

Sheena Mesa:
Sure, Adam. This report looks at several issues related to quality of care for a patient who reported to the Chillicothe VA Medical Center in Ohio in 2021 with back pain. The case highlights the importance of clear documentation in the medical record and how miscommunication among providers and healthcare teams can compromise patient safety.

Adam Roy:
So, we’re going to be looking at a singular patient history. Can you tell us what the OIG found when reviewing the care of this patient?

Sheena Mesa:
Certainly. One of the most concerning allegations that we received was that a provider at the urgent care center sent a patient with a compression fracture in his thoracic spine to have chiropractic care at the complementary and alternative medicine, or CAM, clinic. The allegation also suggested that the chiropractic care worsened the patient’s fracture and caused additional fractures of the right 11th and 12th ribs.

Adam Roy:
Wow. Okay, go back and explain a few things you mentioned there. Help the listener understand what the purpose of the urgent care center is.

Sheena Mesa:
An urgent care center provides medical care for patients without scheduled appointments who need immediate attention for a serious medical or mental health illness, or minor injuries.

Adam Roy:
And what is CAM?

Sheena Mesa:
Complementary and alternative medicine, or CAM, is medical care that is not part of conventional medicine. Chiropractic care would be an example of CAM.

Adam Roy:
Let’s talk about the fracture in the patient’s spine.

Sheena Mesa:
Absolutely. The thoracic portion of the spine is commonly called the middle back of the spine. A compression fracture is a way of describing a broken bone.

When the patient was first seen and received chiropractic care, the patient already had a broken bone in the middle back area. When the patient returned to the urgent care center after a week, the compression fracture was now classified as a burst fracture. This meant that the bone in the patient’s middle back was broken in multiple directions. The patient’s 11th and 12th ribs were also broken.

Adam Roy:
So, was it inappropriate for the provider to refer this patient for chiropractic care when he had the compression fracture? How did that happen?

Sheena Mesa:
Well, here’s where it gets a bit complicated. We found that the urgent care provider evaluated the patient and reviewed a recent CT scan of the patient’s spine that was performed at a non-VA facility and that showed the compression fracture. The provider then called and arranged for an end-of-the-day pain management consult with a chiropractor in the CAM clinic to address the patient’s back pain. According to the provider, the intention was for the patient to get the pain addressed, not to receive chiropractic care.

Adam Roy:
Can you further explain why then did the patient ended up receiving chiropractic manipulation?

Shelby Assad:
Yes. This is really the crux of the case here. While we know that the urgent care provider spoke to the chiropractor about a referral for pain management, the urgent care provider failed to enter a consult into the electronic health record—otherwise known as EHR. That consult would have documented the patient’s diagnosis and clearly explained the need for pain management, not chiropractic manipulation. This was the beginning of several missteps subsequently taken by the staff in the CAM clinic.

Adam Roy:
So, the reason for the referral for chiropractic care was not documented before the patient was seen at the CAM clinic. What happened next?

Shelby Assad:
Unfortunately, here is where things got worse. The CAM providers did not follow their standard practice, which includes reviewing a consult from a referring provider and relevant imaging studies in the patient’s EHR and then documenting the care they provided to the patient.

Adam Roy:
So, now I’m starting to understand, as you mentioned earlier, how important documentation is in these situations. You mentioned CAM providers. Did more than one provider in the CAM clinic see this patient?

Shelby Assad:
Yes. A chiropractor in the CAM clinic evaluated and treated the patient for pain. Then he referred the patient to be seen by the clinical massage therapist

Adam Roy:
To summarize, if I can here, the chiropractor and the massage therapist both treated the patient without reviewing the consult because the urgent care provider had not entered the consult into the system, as required by VHA policy. Is that accurate?

Shelby Assad:
Yes, that is.

Adam Roy:
Why didn’t the chiropractor follow that standard practice in this case?

Shelby Assad:
This part becomes very unclear. Because the chiropractor did not document the care provided to the patient, the chiropractor had no reference point to help him remember the patient or the care provided. By the time we spoke with the chiropractor during our inspection, he had no memory of the patient, the care provided to the patient, or an explanation of why he didn’t follow his standard practice.

Adam Roy:
What about the massage therapist?

Shelby Assad:
The clinical massage therapist did not remember the name of the patient when we interviewed them but recalled treating a patient who presented with a similar problem. The clinical massage therapist recalled that a consult was not entered.

Because the initial consult was not entered into the electronic health record, the chiropractor and the clinical massage therapist did not document the care they provided to the patient.

Adam Roy:
Was the referral to the CAM clinic for pain management ever documented into the patient’s electronic health record?

Sheena Mesa:
The urgent care provider entered a delayed consult into the electronic health record, and it was more than a week after seeing the patient.

Adam Roy:
You mentioned earlier that when the patient returned to the urgent care center a week after treatment, they had a burst fracture and two broken ribs. Did the problems that your team identified cause these injuries?

Sheena Mesa:
Because of the lack of documentation and provider recall, we could not conclusively determine the relationship between the care received at the CAM clinic and the patient’s bone fractures.

Adam Roy:
What were the OIG’s final recommendations in this report?

Shelby Assad:
Ultimately, we recommended that the facility director ensure urgent care providers, chiropractors, and clinical massage therapists are educated on the consult processes and procedures. This would include the requirement for timely documentation. We also recommended that the facility director conduct an internal review of the CAM Program processes related to patient care, including receiving and reviewing consults, scheduling appointments, checking-in patients for care, and documentation.

Adam Roy:

That’s a good summary. Thank you. And I think it’s important to state here that your work isn’t finished as I know your team will follow up on these recommendations and work with VA to make those changes that will hopefully improve veteran care and the processes and associated with it.

Sheena and Shelby thank you so much for your time today.

Listeners, if you’re interested in learning more about this report or any other work by the VA OIG, I encourage to visit our website, that’s www.va.gov/oig. There you will find summaries on all reports as well as other information and resources offered by the VA OIG.

I’d like to share a relatively new feature to our website with you now. Check out the VA OIG’s Fraud Toolkit and Crime Alerts. The VA OIG investigates a wide range of potential crimes—from financial crimes to threats against VA personnel and property to actions associated with patient harm.

The toolkit provides a list of key possible indicators specific to various types of fraud. The list is far from exhaustive, but it does identify common signs that VA personnel, contractors, and the veteran community, and maybe some of you listening out there as well, should be aware of in order to report suspicious activity and alleged wrongdoing to the OIG hotline. Examples of potential indicators include compensation benefits fraud, healthcare fraud, public corruption and kickbacks, and fraud related to public health crises, like we have seen recently with the pandemic.

You can find this toolkit right on our home page.

That’s it for this episode of Inside Oversight. Check out other episodes wherever you listen to podcasts.

Thanks for tuning in.

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