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OIG Report: More Than 100 Veteran Deaths Occurred While Waiting For VA Care

Veteran (Department of Defense)
May 09, 2017

Veterans have been experiencing a delay in their healthcare, and a new report from the VA Office of the Inspector General (OIG) brings to light the somber truth.

The OIG conducted an inspection at the VA Greater Los Angeles Healthcare System facility over a 10-month period throughout 2014 and 2015, and it determined that 117 deceased patients with 158 consults had experienced delays in obtaining consultations, according to the 33-page report.

Forty-three percent of consults “were not timely because providers and scheduling staff did not consistently follow consult policy or procedures,” according to the report.

The report, dated May 4, stated that allegations “that patients experienced serious or severe impact with long-term consequences or organ dysfunctions, or that patients died as a result of delayed consults,” were not substantiated. But two patients were identified who experienced intermediate impact or minor impact, according to the report.

The OIG found that providers entered incorrect inpatient/outpatient information for 14 percent of the reviewed consults; entered incorrect consult service settings for 9 percent of consults; and entered incorrect consult urgency for 5 percent of consults, according to the report.

This takes into account 371 consults that were open or pending at the time of patients’ deaths, or consults that were discontinued after their deaths, the report stated.

The OIG also “observed deficiencies in consult management practices [that] contributed to the delays,” the report stated.

The OIG “noted that facility staff did not [act timely] on clinical consult requests, close completed consults or discontinue duplicate requests or consults no longer indicated, or monitor the electronic wait list for Homemaker/Home Health Aide services,” according to the report. “Additionally, scheduling staff encountered challenges scheduling appointments due to patient unavailability or patients not attending scheduled appointments for various reasons.”

The Inspector General had several recommendations for the facility, and the “Veterans Integrated Service Network and Facility Directors agreed with the findings and recommendations and provided acceptable improvement plans,” according to the report.

The OIG stated it would follow up on the planned actions and recommendations “until they are completed.”

The OIG inspection was conducted at the request of Jeff Miller, Committee on Veterans’ Affairs, U.S. House of Representatives, “to determine the validity of an allegation that 74 deceased patients had open consults,” according to the VA report.

The U.S. House of Representatives in March passed legislation “allowing VA officials to terminate, demote or suspend employees based on performance or misconduct,” according to a report in The Blaze.