Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Self-Administered Rescue Medications
 

Specialized Inpatient
 

Stress Disorders Unit
 

VA Eastern Kansas Health Care System
 

Topeka, Kansas
 

Report No. 11-00184-147 April 20, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Executive Summary
 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted a 

review to determine the validity of allegations that a complainant made to the OIG 

Hotline Division. The complainant alleged that the local policy on medication 

management, specifically rescue medications (medications that relieve symptoms 

immediately), was inappropriate and unsafe for the Specialized Inpatient Stress Disorders 

Unit (SIPU) patient population at the VA Eastern Kansas Health Care System, Topeka, 

KS. The purpose of this review was to evaluate whether the current medication 

management policy posed potential risk for patients who need rescue medications when 

they leave the SIPU. The complainant identified rescue medications as nitroglycerin, 

asthma inhalers, and epinephrine pens. 

The SIPU is part of the Colmery-O’Neal VA Medical Center (the facility), Topeka, KS 

and is a 7-week inpatient program for veterans with post-traumatic stress disorder and 

other stress-related disorders. This 24-bed unit is designed to help veterans deal more 

effectively with traumatic experiences that occurred during their military service. The 

SIPU adheres to facility-wide policies appropriate for inpatient units. However, the 

program provides a variety of therapies both in the facility and in the community. The 

facility policy requires that all inpatients, including SIPU patients, relinquish every 

medication upon admission. 

The complainant reported that patients are “at risk for heart attack and death” without 

immediate access to rescue medications because they are not allowed to carry these 

medications with them when they leave the unit. The complainant reported that 

managers had been notified of these concerns. 

We substantiated that the current facility policy does not allow patients to carry rescue 

medications when they leave the unit. SIPU staff identified this as a problem and took 

steps to implement a process that allows patients to carry rescue medications when they 

leave the unit. However, the written facility policy does not reflect the current process. 

We found no patients who had adverse outcomes due to lack of access to rescue 

medications. 

The Veterans Integrated Service Network and Facility Directors concurred with our 

recommendation to develop a formal, written SIPU-specific policy that includes 

procedures for administering rescue medications. The action taken is acceptable and we 

consider the recommendation closed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Director, VA Heartland Network (10N15) 

SUBJECT: Healthcare Inspection – Self-Administered Rescue Medications, 

Specialized Inpatient Stress Disorders Unit, VA Eastern Kansas Health 

Care System, Topeka, Kansas 

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted a 

review to determine the validity of allegations that a complainant made to the OIG 

Hotline Division. The complainant alleged that the local policy on medication 

management, specifically rescue medications,1 was inappropriate and unsafe for the 

Specialized Inpatient Stress Disorders Unit (SIPU) patient population at the VA Eastern 

Kansas Health Care System (the system), Topeka, KS. The purpose of this review was to 

evaluate whether the current medication management policy posed potential risk for 

patients who need rescue medications when they leave the SIPU. 

Background

The system is comprised of two medical centers located in Topeka (the facility) and 

Leavenworth, KS. The system provides inpatient and outpatient medical, surgical, 

mental health, geriatric, and rehabilitative services. It operates 197 hospital beds, 

138 community living center beds, and 202 domiciliary beds. The system is part of 

Veterans Integrated Service Network (VISN) 15. 

The SIPU is a 7-week inpatient program for veterans with post-traumatic stress disorder 

and other stress-related disorders. This 24-bed unit is designed to help veterans deal 

more effectively with traumatic experiences that occurred during their military service. 

At present, there are five SIPUs within Veterans Health Administration (VHA). The 

SIPU adheres to facility-wide policies appropriate for inpatient units. However, the 

program provides a variety of therapies both in the facility and in the community. The 

1 Rescue medications are intended to relieve symptoms immediately. This is in contrast to preventive medications, 

which are taken over a long period of time to prevent or manage symptoms. 

VA Office of Inspector General 1 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

facility’s policy requires that all inpatients, including SIPU patients, relinquish every 

medication upon admission. 

The complainant specifically reported that patients are “at risk for heart attack and death” 

without immediate access to rescue medications because they are not allowed to carry 

these medications with them when they leave the unit. The complainant identified the 

following as rescue medications: nitroglycerin, asthma inhalers, and epinephrine pens. 

The complainant reported that managers had been notified of these concerns. 

Scope and Methodology

We reviewed VHA Directives, facility policies and procedures, quality management 

documents, committee minutes, SIPU program documents, and medical record 

documentation. We conducted telephone interviews with the complainant, system 

leadership, SIPU managers, quality management, and pharmacy staff. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results

Issue: Continuous Patient Access to Rescue Medications

We substantiated that the current formal facility policy does not allow patients to carry 

rescue medications with them when they leave the unit. SIPU staff identified this as a 

problem and took steps to implement a process that allows patients to carry rescue 

medications with them when they leave the SIPU. We did not find evidence that any 

patients had experienced negative outcomes. The formal written facility policy does not 

reflect the current medication administration process on the SIPU. 

The SIPU has been in operation for over 20 years and had used a self-medication process 

in the past that allowed patients to keep their medications in locked bedside lockers. 

Patients would turn in all medications at admission, and the pharmacy would provide 

them a new prescription every 7 days while they were in the SIPU. 

When a new SIPU nurse manager was hired 2 years ago, the self-medication program 

was discontinued and replaced with a totally nurse-administered medication program. 

Nursing service provided additional staff to administer all medications, and pharmacy 

service provided a unit dose machine to support the change in distribution of medications. 

Under the nurse-administered medication program, patients turn in all medications at 

admission, the physician assistant writes orders for medications, the pharmacy fills them 

and dispenses medication as a unit dose, and the nurse administers the medication dose. 

VA Office of Inspector General 2 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

In October 2010, after the new nurse manager made the changes, staff identified a 

problem with the new practice. A patient asked a nurse for a refill of his outpatient 

sublingual nitroglycerin (medication used for chest pain) because he ran out of this 

medication and would be leaving the facility for a community activity and may need it. 

Reportedly, this patient had not relinquished his nitroglycerin at the time of admission. 

The nurse was unsure how to provide the rescue medication for this patient and called the 

pharmacy. Pharmacy informed the nurse that they could not refill an outpatient 

prescription while the patient was an inpatient. In addition, the nurse was told that she 

could not give the patient the unit dose bottle of nitroglycerin to take with him when at 

the community activity. The only way for this patient to receive nitroglycerin was if he 

notified the nurse that he was having chest pain, then the nurse could administer the 

rescue medication. 

As a result, staff became aware that the newly implemented nurse-administered 

medication program did not account for those situations where patients leave the unit and 

need to have rescue medications available, if needed. SIPU staff communicated these 

concerns to facility leadership and implemented a change in practice until a written 

policy could be formally implemented. The physician assistant now assesses the patient 

to determine which medications are appropriate for the patient to self-administer and 

writes an order to nursing staff that allows the patient to keep rescue medications with 

them when off the unit or locked in the bedside locker. Although the practice has 

changed to meet the patients’ needs, the facility policy does not reflect the new process. 

The formal written policy remains that all medications are totally nurse-administered. 

Conclusion

At the time of the allegation, a formal written policy was not in place to provide patients 

access to rescue medications when attending activities off the unit. However, we did not 

find any patients who had adverse outcomes as a result. The informal change in practice 

provides a work-around that facilitates patient access to rescue medications while off the 

unit. However, in the absence of a formal written change in policy, nursing staff are 

placed in a position whereby they are technically dispensing medications when they give 

patients a 7-day supply of rescue medications. 

The Facility Director and Chief of Staff were aware of the changes in medication 

administration and agreed that the policy needed to be revised to reflect the actual 

practice on the unit. They had referred the issue to the appropriate committee for action. 

At the time of our review, the committee had not yet revised the written policy. 

Recommendation

We recommended that the facility develop a formal, written 

SIPU-specific policy that includes procedures for administering rescue medications. 

VA Office of Inspector General 3 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Comments

The VISN and Facility Directors concurred with the inspection results (see Appendixes A 

and B, pages 5–7, for the full text of their comments and completed action). The action 

taken is acceptable and we consider the recommendation closed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 4 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: April 5, 2011
 

From: Director, VA Heartland Network (10N15)
 

Subject: Healthcare Inspection – Self-Administered Rescue Medications,
 

VA Eastern Kansas Health Care System, Topeka, Kansas 

To: Director, Kansas City Office of Healthcare Inspections (54KC) 

Thru: Director, Management Review Service (10B5) 

Concur with OIG review and recommendation. The action plan was 

completed on March 24, 2011. 

(original signed by:) 

JAMES R. FLOYD, FACHE
 

Director, VA Heartland Network (10N15)
 

VA Office of Inspector General 5 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Appendix B

System Director Comments

Department of

Veterans Affairs Memorandum

Date: April 4, 2011
 

From: Director, VA Eastern Kansas Health Care System (589A5/00)
 

Subject: Healthcare Inspection – Self-Administered Rescue Medications,
 

VA Eastern Kansas Health Care System, Topeka, Kansas 

To: Director, VA Heartland Network (10N15) 

Concur with OIG review and recommendation. The action plan was 

completed on March 24, 2011. 

JUDY K. MCKEE, FACHE
 

Director, VA Eastern Kansas Health Care System (589/A5)
 

VA Office of Inspector General 6 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comment is submitted in response to the 

recommendation in the Office of Inspector General’s report: 

OIG Recommendation 

Recommendation. We recommended that the facility develop a written 

SIPU-specific self-medication policy that includes procedures for 

administrating rescue medications. 

Concur Recommend Closure 

Facility’s Response: 

Facility developed a policy for Medications For Self-Administration On 

The Stress Disorder Treatment Program on March 24, 2011. 

VA Office of Inspector General 7 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact	 Dorothy Duncan, RN, Director 

Kansas City Office of Healthcare Inspections 

Acknowledgments	 Jennifer Kubiak, RN, Team Leader 

Michael Shepherd, MD 

Laura Tovar, LCSW 

Jennifer Whitehead 

VA Office of Inspector General 8 
Self-Administered Rescue Medications, VA Eastern Kansas Health Care System, Topeka, Kansas 

Appendix D

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, VA Eastern Kansas Health Care System (589A5/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Jerry Moran, Pat Roberts 

U.S. House of Representatives: Tim Huelskamp, Lynn Jenkins, Mike Pompeo, 

Kevin Yoder 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 9