Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) to assess allegations that facility staff delayed ordering medications following a patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide. The OIG found a community care nurse provided inadequate care coordination, including delayed and omitted clinical documentation. The OIG determined this limited primary care staff's ability to provide care in advance of and after discharge from the community hospital. Primary care staff care coordination process deficiencies contributed to a delay in the patient’s discharge medications. Primary care staff failed to provide health education to the patient about how to obtain the prescribed medications and did not provide same day access to address a lapse in cardiac medication. Additionally, the primary care provider failed to order the patient’s discharge medications. The OIG determined that a VISN physician lacked critical clinical information, did not conduct a complete medication reconciliation, and lacked knowledge of the process to order the patient’s anticoagulant medication, contributing to the delay in ordering medication. The OIG found primary care staff failed to notify suicide prevention staff of the patient’s death by suicide and failed to complete a suicide behavior overdose report immediately upon notification. Further a former suicide prevention program manager failed to timely complete the behavioral health autopsy and a family interview tool contact form. The OIG made one recommendation to the VISN Director to review the patient’s care and take actions as warranted and four recommendations to the Facility Director related to community care coordination, primary care, actions required following a patient death by suicide, and to take actions as warranted.