Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Quality of Care Provided at Corpus
 

Christi Community Based Outpatient
 

Clinic
 

VA Texas Valley Coastal Bend Health
 

Care System
 

Harlingen, Texas
 

Report No. 11-02548-291 September 29, 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)
 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted a review 

to determine the validity of allegations made by a complainant regarding quality of care 

at the Corpus Christi Community Based Outpatient Clinic (CBOC) in Corpus Christi, 

TX. The CBOC is part of VA Texas Valley Coastal Bend Health Care System in 

Harlingen, TX (the facility). The complainant specifically alleged that: 

	 A provider did not diagnose a patient’s fractured ankle when the patient presented 

with right foot pain after a fall. 

	 A provider diagnosed a patient with pressure ulcers rather than abscesses caused 

by medication injections, and treated the patient with antibiotics without obtaining 

wound cultures. 

We substantiated that a CBOC primary care provider did not diagnose a patient’s 

fractured ankle when the patient presented for evaluation. The facility had taken 

appropriate action prior to our review. 

We substantiated that a CBOC primary care provider prescribed antibiotics without first 

obtaining wound cultures. The primary care provider acknowledged that it was the usual 

practice to obtain a specimen for culture when drainage was present in a wound prior to 

starting antibiotics. 

We identified two additional factors that affected this patient’s care: 

	 Failure to implement the facility’s Skin Integrity Management Program Policy for 

managing the skin integrity of outpatients. 

	 Fee-basis records are not always available in the medical record. The facility 

identified opportunities for improvement prior to our review. We found their plan 

acceptable. 

We recommended that the Medical Center Director ensure that the CBOC follow the 

Skin Integrity Management Program Policy. 

The Veterans Integrated Service Network and Medical Center Directors concurred with 

our findings. We will follow up until the planned actions are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Director, VA Heart of Texas Health Care Network (10N17) 

SUBJECT: Healthcare Inspection – Quality of Care Provided at Corpus Christi 

CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, Texas 

Purpose 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations made by a complainant regarding 

quality of care at the Corpus Christi Community Based Outpatient Clinic (CBOC) in 

Corpus Christi, TX. 

Background 

The CBOC is part of VA Texas Valley Coastal Bend Health Care System (HCS) in 

Harlingen, TX (facility) and Veterans Integrated Service Network 17 located in 

Arlington, TX. The CBOC provides outpatient healthcare including primary care, mental 

health, orthopedic, nutrition, podiatry, social work, and physical therapy services. The 

clinic serves a population of approximately 15,000 veterans. The CBOC is 

approximately 135 miles from the facility. 

The Veterans Health Administration (VHA) established the facility in December 2008 to 

provide a variety of outpatient specialty care. The facility provides inpatient care via 

contracts. The facility uses fee-basis referrals for specialty care that are not available at 

the CBOCs or facility. VHA policy1 requires facilities to scan the reports and other 

results of fee-basis referrals into the patient’s medical record. 

In May 2011, a complainant contacted OIG’s Hotline Division with allegations that 

CBOC physicians were not following standards of care when treating their patients. The 

complainant specifically alleged that: 

1 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA Office of Inspector General 1 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

	 A provider did not diagnose a patient’s fractured ankle when the patient presented 

with right foot pain after a fall. 

	 A provider diagnosed a patient with pressure ulcers rather than abscesses caused 

by medication injections and treated the patient with antibiotics without collecting 

wound cultures. 

Scope and Methodology 

We made a site visit to the CBOC on June 14–15, 2011. We interviewed facility and 

CBOC managers, clinicians, and other staff with knowledge of the complaints. We 

reviewed patient medical records and facility documents. We interviewed one patient for 

clarification after our medical records review. 

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. 

Case Summaries 

Patient 1 

In February 2011, a man in his fifties with a history of diabetes with peripheral 

neuropathy,2 hypertension, high cholesterol, and leg swelling presented to the CBOC for 

a routine primary care appointment. A licensed vocational nurse (LVN) assessed the 

patient prior to the appointment and documented that the patient described loss of 

consciousness, falling, and injuring his right foot. The patient complained that walking 

was painful and rated the pain as an 8 on a scale from 0 to 10. The LVN’s note 

documented primary care provider (PCP) notification of the new, acute pain in the 

patient’s foot radiating to the ankle. 

The PCP’s note documented that the patient presented for management of chronic 

medical problems. The PCP’s note contained a vital signs section with the pain scale of 

eight, but did not address the pain in the body of the note. The PCP documented that 

examination of the extremities showed no swelling and normal pulses. The note states 

that the PCP reviewed images; however, there were no x-rays on record since August 

2009. The PCP documented that a diuretic was controlling the patient’s leg swelling. 

Nine days later, the patient returned to the CBOC requesting a walk-in appointment with 

complaint of right ankle pain. A registered nurse (RN) documented that the patient had 

fallen 12 days prior and was walking slowly with a very swollen right ankle and 

discolored foot. Per triage clinic protocol, the RN sent the patient for an x-ray prior to a 

physician’s examination. A different CBOC physician examined the patient during this 

2 Peripheral neuropathy refers to damage of nerves of the peripheral nervous system. Symptoms include numbness, 

pain, and problems with muscle control. 

VA Office of Inspector General 2 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

visit and the note documented the patient’s fall, subsequent swelling and tenderness of 

the patient’s ankle, and x-ray evidence of an ankle fracture. The physician consulted an 

orthopedic surgeon who recommended a follow-up appointment in 3 days. The surgeon 

discharged the patient with an ankle wrap, crutches, and recommended using ice and 

elevating the ankle. The patient already had an active prescription for pain medication. 

Patient 2 

In September 2010, a female in her fifties with a history of chronic back pain, 

hypertension, tobacco use, and bipolar disorder3 that required intramuscular risperidone4 

injections (given in the hip) every 2 weeks presented to the CBOC complaining of 

chronic pain and skin ulcers at the hip injection sites. The patient’s PCP did not 

document the ulcers in the examination, assessment, or plan during this visit. 

Four days later, the patient returned to the CBOC requesting antibiotics for infections of 

the left and right hip injection sites. The patient’s PCP’s documentation noted small, 

infected lesions. The PCP prescribed an antibiotic for 10 days and instructed the patient 

to return if the symptoms did not improve. 

Over the next two weeks, the patient twice reported to the pharmacist that the wounds 

had not improved, and remained painful and irritated. After a second notice from the 

pharmacist, the PCP scheduled the patient for a return appointment 4 days later. 

At the appointment, the PCP noted the patient’s non-healing hip ulcers. A blood test 

revealed the patient had a normal white blood cell count. The PCP’s plan included daily 

iodoform gauze5 dressing changes until the ulcers healed with follow up in 3 months. 

The patient’s home care RN was to continue weekly visits and perform the dressing 

changes. The patient’s roommate changed the dressings when the RN was not scheduled 

to visit. 

In November 2010, the home health RN documented that both hip ulcers were not 

improving, were tunneling,6 and had purulent drainage7 that required dressing changes up 

to 3 times per day. The RN requested a PCP appointment for re-evaluation. 

In Mid-November at the next primary care appointment, the PCP noted a deep, nonhealing, non-draining ulcer with slight redness. The PCP prescribed two antibiotics for 

10 days, recommended continuing daily dressing changes, and requested the patient 

follow up in 2 months. 

3 Bipolar disorder involves periods of elevated or irritable mood, alternating with periods of depression.
 4 Risperidone is a medication used to treat the symptoms of bipolar disorder.
 5 Iodoform gauze is a type of sterile gauze treated with iodoform (an antiseptic). The gauze is placed in wounds to
 

help the wound drain.

6 Tunneling is a narrow opening or passageway underneath the skin that can extend in any direction through soft
 

tissue and results in dead space with potential for abscess formation.

7 Purulent drainage is thick, yellow, green, or brown in color with a pungent, strong, foul odor.
 

VA Office of Inspector General 3 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

The home health RN continued to document that the ulcers were not healing, had large 

amounts of purulent drainage, and had tunneled deep into subcutaneous tissue.8 After 

2 weeks, the RN requested a consult for surgical incision and drainage. 

Three days later, a CBOC physician entered a fee-basis consult at the request of the RN 

for surgical incision and drainage of tunneling abscesses. The consult was approved 

15 days later in mid-December. The next day, the home RN scheduled an appointment 

with a fee-basis surgeon. 

In Mid-December, the patient saw a fee-basis surgeon and reported to the home health 

RN that the surgeon did not prescribe an incision and drainage of the hip ulcers. The 

home health RN contacted the surgeon’s office to confirm the surgeon’s 

recommendations directly. The surgeon requested a home health wound care RN for 

daily wound care using saline irrigation and dry packing, rather than iodoform gauze, for 

optimal wound healing. The surgeon also requested a bone scan9 for the patient to rule 

out osteomyelitis.10 Home health daily wound care began the next day. A bone scan was 

completed the end of December. 

Two days after the bone scan was completed, the patient presented to the CBOC with 

draining hip abscesses that were without redness or tenderness. The physician changed 

the diagnosis from pressure ulcers to abscesses. The physician ordered wound cultures, 

wound packing, and continuation of home health wound care. This physician prescribed 

a different antibiotic and requested an appointment for the patient to return in 4 days for 

wound checks and culture results. 

In early January, on the day of the patient’s scheduled follow-up appointment, the patient 

cancelled due to illness. On that same day, a CBOC physician reviewed the wound 

culture results that indicated the infection was not sensitive to the current antibiotics, and 

a CBOC RN called the location where the patient had the bone scan and obtained the 

results. The CBOC physician noted that the scan was suggestive of osteomyelitis in the 

left hip region and decided to admit the patient for treatment with intravenous antibiotics. 

The patient agreed with the physician’s plan for hospital admission. Further testing 

during the hospital admission showed the patient did not have osteomyelitis. 

Inspection Results 

Issue 1: Delayed Diagnosis 

We substantiated that the PCP did not diagnose the patient’s fractured ankle when the 

patient first presented with ankle pain. 

8 Subcutaneous tissue is the third layer of the three layers of skin and contains fat, connective tissue, larger blood
 

vessels, and nerves.

9 A bone scan is a nuclear imaging test that helps diagnose and track several types of bone disease, including bone
 

infection, that are undetectable on a standard x-ray.
 10 Osteomyelitis is an infection of the bone that is usually bacterial.
 

VA Office of Inspector General 4 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

The LVN’s note documented the patient “blacked out,” fell, and was complaining of right 

foot pain. During our interview, the LVN stated that the PCP was informed of the 

patient’s fall and foot pain. During a phone interview, the patient stated that the PCP 

examined his foot, assured him that there was nothing wrong, and that his right leg 

swelling was from water retention. The patient informed the PCP that the fall resulted 

from the episode of loss of consciousness. One week later, the patient returned to the 

clinic, the RN triaged the patient and obtained an x-ray of his ankle. A different PCP 

diagnosed an ankle fracture and referred the patient to orthopedic surgery. The 

orthopedic surgeon told us that the delay in diagnosis caused no adverse effects. 

Issue 2: Inappropriate Treatment of Wounds 

The concerns we had with this patient’s care are that her abscesses (caused by 

intramuscular injections) continued to worsen without appropriate interventions. 

Specifically, the PCP continued to treat these lesions as if they were pressure ulcers, 

rather than abscesses. Although there was visiting nurse support, there was insufficient 

clinic follow-up, re-evaluation, and re-assessment. Ultimately, clinicians became 

concerned about the possibility of osteomyelitis and hospitalized the patient. Much of 

this may have been avoided with better wound care. 

The CBOC had not implemented the facility Skin Integrity Management Program Policy 

for managing the skin integrity of outpatients as required. Local policy states that a clinic 

RN trained in wound care coordinates and assists the team with wound management and 

continuity of wound care in ambulatory care clinics. Although the policy targets the 

management of pressure ulcers, had it been implemented, this nurse would have been 

involved in the care of this patient when the PCP initially diagnosed the patient. 

Issue 3: Fee-basis Consult Tracking 

In October 2010, the CBOC became part of the new facility that does not have all 

specialty services readily available. The lack of in-house specialty care required the use 

of fee-basis care in the local community. To obtain fee-basis care a CBOC physician 

must submit a fee-basis consult for approval. VHA requires consults be addressed within 

7 days.11 Once the fee-based care is approved, the patient is notified and told to make an 

appointment with a community provider that can provide the specified care. The 

referring CBOC physician is not always aware if, when, or with whom an appointment is 

made. Further, the fee-basis provider’s results that are sent to the clinic are not always 

present in the patient’s medical record. During this episode of care, neither the surgical 

consult nor bone scan report were available to the CBOC physicians. 

The facility and CBOC had identified opportunities for improving the fee-basis process 

prior to our review. The plan includes hiring and assigning a fee-basis clerk to each of 

the facility’s CBOCs, assigning duties to primary care team members to facilitate 

11 VHA Directive 2008-056, VHA Consult Policy, September 16, 2008. 

VA Office of Inspector General 5 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

scheduling and obtaining results, and hiring specialty physicians at the facility to reduce 

the need for fee-basis consults. 

Conclusions 

A CBOC PCP failed to diagnose a patient’s fractured ankle when he first presented with 

ankle pain; however, the facility took appropriate action prior to our review. 

A CBOC PCP did not obtain wound cultures before prescribing antibiotics. The 

physician acknowledged that wound cultures should have been obtained prior to starting 

the course of antibiotics. 

CBOC management did not implement the facility’s Skin Integrity Management Program 

as required. Involvement of a CBOC RN trained in wound care early in this patient’s 

care would have been prudent. 

We found that it took 15 days to get fee-base approval for this patient to see a surgeon. 

In addition, the fee-basis bone scan report was not available to the CBOC staff until after 

they requested the report in early January. The facility is actively addressing these issues. 

Recommendation 

Recommendation. We recommended that the Medical Center Director ensure that the 

CBOC follow the Skin Integrity Management Program Policy. 

Comments 

The Veterans Integrated Service Network and Medical Center Directors concurred with 

our findings (See Appendixes A and B, pages 7-9, for the full text of their comments). 

We will follow up until the planned actions are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 6 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Appendix A 

Veterans Integrated Service Network Director
 

Comments
 

Department of 

Veterans Affairs Memorandum 

Date:	 September 2, 2011 

From:	 VA Heart of Texas Health Care Network (10N17) 

Subject:	 Healthcare Inspection – Quality of Care Provided at 

Corpus Christi CBOC, VA Texas Valley Coastal Bend 

HCS, Harlingen, Texas 

To:	 Director, Dallas Office of Healthcare Inspections (54DA) 

Thru:	 Director, VHA Management Review Service (10A4A4) 

1.	 Thank you for allowing me to respond to this Healthcare 

Inspection regarding the Quality of Care provided at the 

Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, 

Harlingen, Texas. 

2.	 I concur with the recommendation and have ensured that an 

action plan has been developed. 

3.	 If you have further questions regarding this inspection, please 

contact Judy Finley, Quality Management Officer at 

817-385-3761 or Denise B. Elliott, VISN 17 HSS at 

817-385-3734. 

(original signed by:) 

Lawrence A. Biro
 

Director, VA Heart of Texas Health Care Network (10N17)
 

VA Office of Inspector General 7 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Appendix B 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 September 1, 2011 

From:	 Jeffery L. Milligan, Director, VA Texas Valley Coastal Bend 

HCS (740/00) 

Subject:	 Healthcare Inspection – Quality of Care Provided at 

Corpus Christi CBOC, VA Texas Valley Coastal Bend 

HCS, Harlingen, Texas 

To:	 Lawrence Biro, Director, VA Heart of Texas Health Care 

Network (10N17) 

1. I concur with the findings noted in this report.	 Action 

plans have been developed and monitoring will be 

conducted on a regular basis. 

2. Should you require additional information, please contact 

Cathy Mezmar, Chief, Quality Management, 956-430-

9343. 

(original signed by:) 

Jeffery L. Milligan
 

Director, VA Texas Valley Coastal Bend HCS (740/00)
 

VA Office of Inspector General 8 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation. We recommended that the Medical Center Director 

ensure that the CBOC follow the Skin Integrity Management Program 

Policy. 

Concur Target Completion Date: October 19, 2011 

Facility’s Response: 

A mandatory training addressing PM 118-10-04 Skin Integrity Management 

Program Policy and basic wound management will be conducted by Nursing 

Education for Patient Aligned Care Teams (PACT) nurses, dietitians, social 

workers, and a designated physician at each CBOC. 

Status: Open 

VA Office of Inspector General 9 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Cathleen King, MHA, CRRN, Project Leader 

Gayle Karamanos, MS, PA-C, Team Leader 

Larry Ross, MS 

Monika Gottlieb, MD, Medical Consultant 

Misti Kincaid, BS, Program Support Assistant 

VA Office of Inspector General 10 
Quality of Care Provided at Corpus Christi CBOC, VA Texas Valley Coastal Bend HCS, Harlingen, TX 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heart of Texas Health Care Network (10N17) 

Director, VA Texas Valley Coastal Bend HCS (740/00) 

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: Kay Bailey Hutchison, John Cornyn 

U.S. House of Representatives: Blake Farenthold, Ron Paul, Mac Thornberry 

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

VA Office of Inspector General 11