Phoenix VA Report Veteran Case Excerpts 31-45

In the Phoenix VA report, which you can download in its entirety here, the VA’s Office of Inspector General discussed 45 cases of veterans reflecting “unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.” The report links 20 veteran deaths to poor care. We present cases 31-45 below:

Phoenix VA reportA man in his mid-60s had a history of prostate cancer, diabetes, PTSD, and morbid obesity. He was followed routinely in Primary Care at PVAHCS.

The patient was diagnosed with prostate cancer at another VA facility in the fall of 2010. He was treated with radiation therapy followed by leuprolide injections.

His last normal recorded PSA was at the “undetectable” level, noted at a 2012 Urology Clinic follow-up appointment. The patient was instructed by the urologist to return in 6 months for an examination and repeat PSA. According to the patient’s EHR, that follow-up appointment was canceled by Urology staff 3 months before the appointment was to occur. There was no evidence in the EHR indicating that staff attempted to contact the patient to reschedule this appointment.

Three months after the “canceled” appointment, during a Compensation and Pension examination, another PSA level was ordered. The result showed a value of 0.90 ng/ml. (In a patient with a history of prostate cancer and a history of post-treatment undetectable PSA levels, any measurable PSA suggests recurrence of disease.) Seven months later, as part of a routine appointment, the patient’s PCP ordered laboratory tests, including a PSA. The value was then 98 ng/ml. A Urology Service consult was placed.

Later that month, the patient was seen at the PVAHCS ED complaining of 2 months of back pain. X-rays revealed lytic (bone destructive) lesions in his lumbar spine, presumably from metastatic prostate cancer. Urology evaluated the patient that same day, and treatment was initiated. In early 2014, the patient was admitted to hospice; he died 2 months later.

At one of this patient’s canceled Urology Service appointments, providers might have identified or confirmed the patient’s rising PSA, which could have prompted an earlier initiation of aggressive treatment.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his late 50s was hospitalized at PVAHCS in late 2013 after liver nodules were found on a CT scan obtained at a non-VA hospital. A liver biopsy was required for a definitive diagnosis, and this was anticipated to be done after discharge from PVAHCS. Two Schedule an Appointment consults were entered during that inpatient stay—both for Primary Care and both were routine. Two days after discharge, a post-hospitalization call was made to the patient, but staff were unable to make contact with the patient, as his listed contact information was incorrect. Two additional attempts to reach the patient and discuss biopsy scheduling were also documented.

A week after discharge the patient was seen in the PVAHCS ED. He was under the impression that he was to return that day to be admitted for a liver biopsy. He was sent home and advised to contact his PCP; he was seen in Primary Care 3 days later at an initial visit to establish care.

One week later, the patient was readmitted to PVAHCS for severe groin pain and worsening edema. He was evaluated by the Hematology/Oncology Service the following day, but because of his advanced disease, chemotherapy was not advised. He died 3 days later in the PVAHCS Community Living Center hospice unit.

In the care of this patient, there was significant confusion surrounding when or if the patient would have a liver biopsy. Given his clinical state, when the patient returned to the ED with intractable abdominal pain and probable metastatic disease, an admission for pain control should have been considered. Ultimately, a biopsy was not performed due to impaired blood coagulation, making the risk of bleeding complications too great to safely undergo the procedure.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his mid-60s had a history of aortic valve replacement and was being treated with an anticoagulant medication. He also had a history of coronary heart disease, hypertension, and iron deficiency anemia. He was followed routinely at PVAHCS and was admitted from the ED in the summer of 2013 for an abnormality in his bloodwork that suggested his anticoagulant dosage needed adjusting. At that time, he reported symptoms of fatigue and blood in his stool, received iron infusions, and was discharged with plans to get a colonoscopy and upper gastrointestinal endoscopy as an outpatient. The patient was contacted 5 days after discharge to set up an appointment with gastroenterology, but he informed the caller that he planned to get his care “outside the VA.” For the following 3 months, the patient’s only contact with PVAHCS was with the Anticoagulation Clinic staff.

Six weeks after discharge from the hospital, the patient reported to the Anticoagulation Clinic pharmacist that he had dizziness and a low home blood pressure reading (93/47 mm Hg). The pharmacist advised the patient to hold his blood pressure medications, come to the clinic for an evaluation, and contact his provider. On the following day, the patient’s PVAHCS PCP acknowledged receipt of the pharmacist’s note. The final note in the EHR was approximately 5 weeks later when the patient’s wife called to inform facility staff of his death.

This patient had symptomatic hypotension that was brought to the attention of a PCP. There is, however, no indication that anyone from Primary Care attempted to contact the patient. Though it appears in the record that the patient was getting private medical care, a patient reporting symptomatic hypotension should have been immediately contacted by a staff member to ensure an appropriate evaluation.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his mid-60s had a history of tobacco use and persistent cough. He presented to the PVAHCS ED in the spring of 2013 with symptoms suggestive of an acute stroke. He was admitted, and during the hospitalization, a chest X-ray revealed a large density in the right lung. The radiologist recommended a CT scan of the chest for further evaluation of this lesion. The discharge summary from that admission cited the lung abnormality and advised that the patient make an appointment in Primary Care, and obtain a CT scan of his chest in 2 months.

Six weeks later, the patient presented to the ED complaining of shortness of breath. He was admitted to the facility and diagnosed with advanced non-small cell lung cancer. The patient was discharged to home hospice and died several days later.

This was a patient with a newly described lung mass who required further diagnostic evaluation. If the CT scan could not have been performed during the patient’s hospitalization, an acceptable alternative would have been to discharge the patient with a scheduled appointment in radiology. The hospital discharge plan specified that the patient should schedule an appointment in Primary Care in 1–2 weeks and “obtain a CT scan of the chest in two months”; this is an unacceptable follow-up recommendation for a large lung mass in a patient with a history of cough and tobacco use.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his late 40s with a history of depression presented to the PVAHCS ED in July of 2013. He had been living on the West Coast, getting private psychiatric care, when he began having paranoid delusional thoughts. He called his parents in Arizona asking for help. They traveled to his home and brought him immediately to the PVAHCS ED.

The patient was evaluated by a mental health nurse in the ED. The patient reported to the nurse that he had been started on sertraline 5 days earlier. Additionally, he commented that 6 years prior, he had been prescribed paroxetine but had to stop taking this medication when he began having suicidal thoughts. He denied any history of suicide attempts and also denied any current suicidal or homicidal ideation. He declined hospital admission but did agree to stay with his parents and report to the Mental Health Clinic the following morning. At approximately 11 a.m. the following morning, the patient committed suicide.

This patient’s symptoms at presentation were consistent with a depression-induced psychosis. Given his previous reaction to an antidepressant medication, as well as the fact that he was recently started on another antidepressant, hospital staff should have pursued processes for involuntary admission.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his late 60s had a history of multiple medical problems with depression and chronic pain. He was hospitalized at PVAHCS after presenting to the facility’s Mental Health Clinic in the spring of 2012. He continued to be followed by Primary Care, with some limited involvement of the Pain Clinic. His last primary care visit was in the spring of 2013 for pain control follow-up; at that time his pain medications were adjusted, his sleeping medication dose was increased, and he was instructed to return in 6 months.

Three days later, the patient presented to the ED complaining of ongoing pain that was unresponsive to treatment. Though the patient denied suicidal or homicidal ideation at this visit, the ED physician documented that the patient stated, “the pain is so frustrating, it might make him suicidal.” The patient was described as “despondent” when he left the ED after being given a cervical collar and pain medication.

Several days later, the patient presented unscheduled to the Primary Care Clinic and was evaluated by a registered nurse. He denied suicidal or homicidal ideation. According to the EHR, “Vet states is in ‘so much pain right now I could cry’.” The nurse documented that she suggested he report to the Mental Health Walk-In Clinic, but the patient declined.

On the same day, the patient called the National Suicide Prevention Hotline. He complained of severe and chronic pain unresponsive to treatment, but no response is recorded regarding questions about suicidal ideation or intent. According to the EHR, the “Veteran stated his doctor is not calling him back.” A consult was sent to the local SPC at PVAHCS, but the consult was closed with a comment from the local SPC: “Call not related to SDV [self-directed violence]. Will forward to Veteran’s PACT team. Please close consult.” Six days later, the patient committed suicide.

Because of his past hospitalization for suicidal ideation, his voicing of ideas about suicide in the ED, and his call to the National Suicide Prevention Hotline, this patient should have been identified and managed as a patient at high risk for suicide.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

 

Phoenix VA reportA man in his 60s moved to Phoenix in August 2010 to care for his elderly mother. He reported a history of chronic cough and occupational exposure to asbestos to a PVAHCS provider 2 months later. A chest X-ray showed a suspicious lesion, and the patient underwent a CT-guided lung biopsy in early December. The biopsy did not reveal malignancy, but it was noted that the tissue may not “represent the lesion” and close follow-up was recommended. A request for a CT scan to be done 3 months later was entered, but the scan was never scheduled, and the order was canceled with a comment from the radiology staff to “resubmit if needed.”

The patient was seen for a routine appointment 5 months after the biopsy, but there was no documented discussion of the CT scan and the scan was not reordered. The patient was seen 5 months later, and X-rays were obtained to evaluate knee pain. About 3 weeks later, he was seen in the ED with persistent leg pain.

Eleven months after the lung biopsy, a PVAHCS social worker documented a phone call from a non-VA hospital indicating that the patient had a craniotomy and was diagnosed with metastatic malignant melanoma. He subsequently received comprehensive palliative care at the PVAHCS prior to his death 6 months later.

This patient had poor follow-up care following a lung biopsy. Although the cause of this patient’s death was metastatic melanoma and may not have been related to the lung mass, management of the mass was inadequate.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his late 20s was seen by PVAHCS Mental Health and Primary Care beginning in 2010. He had a history of PTSD, bipolar disorder, and polysubstance abuse. In early 2012, he was hospitalized for suicidal behavior and a psychotic episode related to substance abuse. He completed a sobriety program and was followed by Mental Health every 1 to 2 months for the next several months. His last visit with Mental Health was in the summer of 2012, and his psychiatrist recommended follow-up in “1-2 months, or sooner as needed.” The patient did not keep the follow-up appointment scheduled for 6 weeks after that last appointment, and an attempt to contact him was not made until 12 weeks later. The patient contacted the facility 3 days after the missed appointment and spoke with a nurse about a worsening skin lesion. He was instructed to go to the ED for evaluation, but there were no further encounters with PVAHCS documented. He died 5 weeks later, and the death certificate obtained by OIG states that the cause of death was accidental “acute heroin toxicity.”

This patient was at high risk given recent suicidal behavior and hospitalization with psychosis. He was lost to follow-up after he did not appear for an appointment. More timely attempts to contact the patient should have occurred.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his 30s was first seen at PVAHCS in mid-2011. He had transferred his care from another VAMC, where he had been treated for schizoaffective disorder with disorganized thinking, paranoid ideation, and hallucinations; he also had a history of PTSD. The patient had made three suicide attempts, requiring hospitalization, in the prior 2 years. He was admitted to the inpatient mental health unit at PVAHCS in the spring of 2012 and transferred to a non-VA hospital after assaulting a staff member on the unit.

He presented to the PVAHCS ED 2 months later after calling the crisis line. He reportedly called 911 and said that he was suicidal because he could not afford to stay at his motel. He told the triage nurse that he “hates life and it is so stressful he doesn’t want to be in it.” He was evaluated by a mental health consultant, and his risk for suicide was considered to be low. The patient reported that he “would feel okay if he gets some place to live.” In the ED, he was treated with new medications (loxapine and mirtazapine) with a plan to follow up with his private mental health provider or the PVAHCS Mental Health Walk-In Clinic. The following day the patient committed suicide.

Because this patient had a history of multiple suicide attempts, psychosis, and an unstable housing situation, an admission to monitor initiation of antipsychotic and antidepressant medications would have been a more appropriate management plan.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his 20s had been evacuated from Afghanistan in 2009 because of shrapnel injuries and loss of consciousness. He had a history of seven mental health hospitalizations while in the military and a history of self-injurious behavior. He presented to PVAHCS in September 2012 with anxiety and several weeks later was admitted to a non-VA hospital following a suicide attempt. He was subsequently admitted to the PVAHCS inpatient mental health unit after presenting to the ED complaining of feeling angry all the time. He reported suicidal ideation, thoughts of harming his brother, and his sense that once enraged, he did not know if he could stop himself.

The following day, a team had a conference, to which the patient presented as upset. His mother stated that the patient told his brother that “all I would have to do when I get out is point a gun at a cop and they would shoot me. I won’t have to kill myself.” The patient’s mother expressed concerns regarding the safety of the patient. Documentation noted the patient “is not exhibiting signs of SI/HI [suicidal or homicidal ideation] or medication withdrawal. Veteran’s mother verbalized she was unwilling to petition [pursuit of involuntary admission] him at this time.” He was discharged. Two days later, he was found dead in his apartment of a possible overdose on medication.

There was not a delay in care, but this case raised a quality of care concern. In the context of his presentation the day before and at the conference, his prior mental health history, and the fact that he had not been stabilized on medication, it would have been prudent to either observe or stabilize the patient for a longer period, or for the providers to pursue a petition of involuntary admission, if the patient was unwilling to stay.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his 70s had a history of significant dementia. The case management notes stated, that for a period of time the veteran lived “off the grid,” with no electricity or telephone at his residence. He was followed in a PVAHCS Primary Care Clinic since 2008, at which time he had not been seen by a medical provider for over 4 years. The patient was seen several times in 2008 with his case manager present but then only for an ED visit in May of 2009, at which time he opted not to wait after being triaged for “flu like” symptoms.

The medical record noted that the patient had been scheduled for three appointments in 2010 and 2011, all of which were canceled by the clinic staff without any notation explaining the reason for cancelation. In addition, there is no documentation that attempts were made to reschedule these canceled appointments. A death certificate obtained from the State of Arizona indicated that the patient was found dead in April 2014. The cause of death was listed as “hypertensive and arteriosclerotic cardiovascular disease.”

In a patient with such severe cognitive impairment, his remote and isolated living conditions would have made his care management challenging; however, it is concerning that three appointments were scheduled and subsequently canceled by PVAHCS staff without a documented effort to reschedule. Such a pattern would likely discourage any patient from relying on this facility for his or her health care, but in a patient with such significant cognitive impairment, it is unlikely that he could have initiated the process of rescheduling these canceled appointments.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his mid-50s had a history of hypertension, stroke, chronic hepatitis C, and alcohol and polysubstance abuse disorders. His first presentation to the VA system was when he visited the PVAHCS ED with a complaint of dizziness. He was prescribed medications for nausea and dizziness and discharged. The plan was for the patient to follow up with Primary Care within 1 week.

The patient was admitted to the PVAHCS Substance Abuse Residential Rehabilitation Treatment Program 3 weeks later. He completed the treatment program after approximately 1 month and was discharged, taking only blood pressure medications. A suicide risk assessment completed prior to discharge found the patient’s suicide risk to be “low or nil.” Discharge instructions included that the patient was “to go to eligibility to get a Primary Care physician assigned for further follow up.” Three days after discharge, an appointment to establish care with a PCP was made for 12 weeks later, but the patient committed suicide 2 weeks before the appointment.

Although any relation to the patient’s death is unlikely, this patient should have had follow-up established with a PCP or mental health provider sooner than the 12 weeks that were planned.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his mid-60s had a history of asthma and COPD. He presented to the PVAHCS ED after having been recently discharged from a non-VA hospital with several medications that needed to be filled. A Schedule an Appointment consult was placed that requested Primary Care follow-up “within one week.” Two weeks later, the patient was hospitalized at another non-VA hospital for pneumonia. Three months later, he was again hospitalized for an asthma exacerbation.

He presented to PVAHCS Primary Care approximately 1 week later as a “walk-in,” seeking to have his prescriptions from an outside hospitalization filled. At that time, he received both prescriptions as well as a new patient appointment for 10 days later. The patient completed that appointment and is currently followed as an outpatient.

With the history of asthma and COPD as well as a recent hospitalization, this patient should have received primary care follow-up soon after his initial ED visit. It is possible that earlier management and monitoring within Primary Care may have prevented subsequent hospitalizations.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

REPORT-OIG-PHOENIX-VA-COVERA man in his mid-50s had a past history of hyperlipidemia. He registered for care at PVAHCS in the spring of 2012, requesting a routine appointment in Primary Care. The patient was given an appointment for 4 months later. In mid-June, the appointment was canceled by the “clinic” and not rescheduled. The patient was not made aware of the cancelation and he reported that he showed for the appointment only to discover it had been canceled. There is no evidence in the EHR that the patient was offered another appointment time. At the end of 2013, the patient reported to an outside ED with chest pain and was taken the following day to the cardiology lab for left heart catheterization with stent placement.

A week later, the patient reported to a PVAHCS Primary Care Clinic requesting medications and cardiology follow-up at PVAHCS. The patient was seen by a physician that day, and at that time, a consult for cardiology was placed, as the patient could not afford to “pay out-of-pocket” for a post-procedure cardiology office visit.

The patient also reported that when he submitted all the medical bills from his outside hospital care to the PVAHCS business office, he was denied reimbursement, as “he was not enrolled in a Primary Care Clinic within the VA.”

The delay between the patient’s registration and initial request for care and an actual appointment was excessive, and when that appointment was inexplicably canceled, PVAHCS staff did not attempt to reschedule the patient. In addition, managing the patient’s post-procedure cardiology follow-up and reimbursing him for life-saving interventions at an outside facility failed to happen in a timely and coordinated manner.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014

Phoenix VA reportA man in his late 60s was followed in a PVAHCS Primary Care Clinic. He had a history of diabetes, hypertension, COPD, coronary artery disease, PTSD, depression, and gastroesophageal reflux. He underwent a barium swallow X-ray at a non-VA facility, and 2 days later, home telemetry recorded a blood pressure of 82/67 and that “he’s been terrible sick the past two day since he had his barium swallow … he’s had a terrible headache, chest pain, abdominal pain and constipation.” The patient and his wife presented to his PCP as instructed and were advised to “push fluids, 7 cups water daily,” as the patient’s wife admitted his fluid intake had been low. The patient’s temperature was not taken, no abdominal exam was recorded, and no diagnostic studies were obtained. Two days later, the patient’s wife took him to a non-VA hospital where he was febrile and admitted for urosepsis.

The quality of care concern in this case relates to an incomplete evaluation of an ill hypotensive patient, including the lack of a temperature recording or examination of the abdomen. Earlier treatment could have been initiated if an appropriate evaluation had been conducted.

– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014