Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the West Palm Beach VA Healthcare System in Florida to assess allegations related to a patient’s cancer care coordination. The OIG did not substantiate that the primary care provider failed to coordinate care or that the pulmonologist failed to surveil the patient’s care. However, the pulmonologist did not inform the patient about the results of a computerized tomography (CT) scan or use the mandatory appointment scheduling process as required. Attempts were made by the pulmonologist to discuss the CT scan results with the patient, but the patient canceled the appointments. The pulmonologist responded to the patient’s rescheduling requests by entering notes in the patients’ electronic health record (EHR) instead of using the required appointment scheduling process, resulting in the patient not being seen by the pulmonologist. The OIG identified concerns regarding community care coordination after a facility chiropractor did not follow up on a community care chiropractor’s recommendation for a magnetic resonance imaging (MRI). After meeting with the patient for complaints of back pain, the community care chiropractor’s note and documented recommendation for an MRI were scanned into the patient’s EHR. Although the facility chiropractor acknowledged the note through signature, the OIG found no documented evidence that the facility chiropractor took action to determine if an MRI was needed. The patient received an MRI months later that showed a fracture, likely related to underlying metastatic disease. The OIG made three recommendations to the Facility Director to ensure that pulmonology providers communicate test results to patients and utilize the appropriate appointment scheduling processes, and to ensure that chiropractor providers review community care notes and takes actions as needed.