Report No. 10-03656-89 February 15, 2011

VA Office of Inspector General 

Washington, DC 20420 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Issues with Quality of Patient Care and 

Communication 

Hampton VA Medical Center 

Hampton, Virginia 
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) 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

Executive Summary 

At the request of the Honorable Jim Webb, United States Senator from Virginia, the VA 

Office of Inspector General Office of Healthcare Inspections reviewed the validity of 

allegations regarding quality of care and communication. The patient’s son 

(complainant), who is the primary care giver and holds power of attorney for the patient, 

alleged that his father received poor care at the Hampton VA Medical Center (medical 

center), Hampton, VA. We reviewed allegations from the complainant that: 

• The Emergency Department provided poor care for the patient. 

• Inpatient care and discharge planning were not adequate. 

• The attending hospitalist did not adequately communicate with the complainant 

about the patient’s care. 

• Medical center managers did not promptly respond to the complainant’s concerns. 

We substantiated that the medical center managers and the hospitalist did not adequately 

communicate with the complainant. However, we determined that efforts to improve 

communications between medical center managers, clinical staff and the complainant 

were effective; therefore, we made no recommendations. 

We did not substantiate the allegations that Emergency Department or inpatient staff 

provided poor patient care. However, we did find lapses in the discharge planning 

process. The complainant was not involved in the discharge process as required. 

Further, the patient was discharged home without a discharge instruction sheet or 

medications. We recommended that the Medical Center Director ensure that medical 

center staff conduct discharge planning activities according to requirements and provide 

timely and complete written discharge instructions to patients and family members. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Mid-Atlantic Health Care Network (10N6) 

SUBJECT: Healthcare Inspection –Issues with Quality of Patient Care and 

Communication, Hampton VA Medical Center Hampton, Virginia 

Purpose 

At the request of the Honorable Jim Webb, United States Senator from Virginia, the VA 

Office of Inspector General (OIG) Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations made by a complainant. The patient’s 

son (complainant) alleged that his father received poor care at the Hampton VA Medical 

Center (medical center), Hampton, VA. The complainant, who held power of attorney 

(POA) for the patient, further alleged that medical center staff did not appropriately 

communicate with him. 

Background 

The medical center provides primary, specialty, and long-term care services. It has 

157 hospital beds and 122 community living center beds. The medical center serves a 

veteran population of about 220,000 throughout a 15-county region in eastern Virginia 

and northeastern North Carolina and is under the jurisdiction of Veterans Integrated 

Service Network (VISN) 6. 

In August 2010, the complainant sent a letter to Senator Webb alleging that: 

• The Emergency Department (ED) provided poor care for the patient. 

• Inpatient care and discharge planning were not adequate. 

• The attending hospitalist did not adequately communicate with the complainant 

about the patient’s care. 

• Medical center managers did not promptly respond to the complainant’s concerns. 

Scope and Methodology 

On September 27–29, 2010, we conducted a site visit to evaluate the complainant’s 

allegations. We interviewed the complainant, clinical staff, medical center managers, and 

other medical center employees knowledgeable about the patient’s care. We reviewed 

the patient’s medical record, pertinent medical center documents, and applicable medical 

center and Veterans Health Administration (VHA) policies. 

VA Office of Inspector General 1 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

VA Office of Inspector General 2 

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 1: Emergency Department Care 

We did not substantiate the allegations that the ED provided poor care for the patient. 

The patient in his eighties received care at the medical center for several chronic medical 

problems. These problems included dementia1

, seizure disorder, high blood pressure, 

and swallowing problems. The patient’s daughter lived close to the medical center; 

however, the complainant, who cared for the patient and held POA, lived 2 hours away 

from the medical center. 

In mid-June, 2010, the complainant brought the patient to the ED because of coughing 

and congestion symptoms. The ED physician ordered several tests. A chest x-ray report 

showed that the patient’s lungs did not have an infection. However, a radiologist noted 

the presence of plaque, suggestive of asbestosis.2

 The laboratory reports, computerized 

axial tomography of the head, and the physician’s examination did not indicate any new 

problems or infection. The ED physician prescribed intravenous (IV) fluids and, after 

several hours, determined that the patient was stable for discharge from the ED. The ED 

staff provided instructions for the patient to continue his medications, return to the ED if 

his condition worsened, and keep a primary care (PC) appointment scheduled for the 

following week. 

Six days later, the PC physician examined the patient, found him to be medically stable, 

and added asbestosis to the patient’s problem list as a result of his recent x-ray report. 

The patient left the PC clinic with prescribed medications. 

Nine days later, the complainant brought the patient back to the ED because of an 

abscess3

 on the patient’s back, increased coughing, congestion, and shortness of breath. 

Because of his medical conditions and chest x-ray results, the ED physician admitted the 

patient with a diagnosis of aspiration pneumonia.4

 The patient was treated with 

antibiotics and, after his breathing function improved, he was discharged home 7 days 

later. 

 

1

Dementia is a disorder of the brain which causes a progressive loss of memory, reasoning, and thinking. 

2

 Asbestosis is a chronic and incurable disease caused by breathing in asbestos over the course of many years. 

Symptoms of asbestosis include shortness of breath and coughing. 

3

 An abscess is a painful, red, and swollen tissue that fills with pus. 

4

 Aspiration pneumonia is a lung infection that is caused from inhalation of food, stomach contents, or other foreign 

matter into the airway. 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

VA Office of Inspector General 3 

Six days post discharge, the patient returned to the ED because of coughing, congestion, 

and shortness of breath. The completed medical tests did not show any new problems or 

infection, so the ED physician discharged the patient with nebulizer treatments.5

 

One month later, the complainant and the patient returned to the ED because the patient 

had significant coughing and mucus production. The complainant reported that the 

patient had the same symptoms as before and may have aspirated.6

 The ED physician 

examined the patient and ordered laboratory tests and a chest x-ray. The patient was 

diagnosed with bronchitis and sent home with antibiotic medications. The next day, the 

complainant again brought the patient to the ED, reporting that his condition was too 

poor for him to be cared for at home. The ED physician admitted the patient to the acute 

medical unit with a diagnosis of dehydration and “failure to thrive.”7

 Upon examination 

the patient was reported to also have a pressure sore on the lower back. 

We determined that the care given in each of the ED visits was appropriate. 

Issue 2: Inpatient Care and Discharge Planning 

We did not substantiate the allegations that inpatient clinicians provided poor patient 

care. However, we did find lapses in the discharge planning process. 

In early July 2010, the patient was admitted to the medical center’s intensive care unit for 

treatment of aspiration pneumonia. Treating physicians ordered chest x-rays, laboratory 

tests, wound care for the abscess on the patient’s back, as well as nutrition and speech 

pathology consultations for swallowing and diet evaluations. The patient’s medical 

treatment included oxygen therapy, nebulizers, IV fluids, and antibiotic medications. 

Following transfer to a general medical bed, the patient was treated and determined to be 

medically stable for discharge on hospital day 7. 

The pharmacist told us that when she delivered the prescribed discharge medications to 

the patient’s room, he was alone, so she instructed him on his medication, placed the 

bottles on his bed, and exited the room. Although local policy requires that staff scan 

printed discharge instructions into the patients’ medical records, the scanned list of 

discharge medications for this patient could not be found. A partial list of scanned 

discharge instructions documented, “no diet restrictions”; however, because of 

swallowing problems and aspiration pneumonia diagnosis, the patient required pureed 

foods and thickened liquids. 

The complainant described to us that he was unaware that the medical center intended to 

discharge the patient until he received a telephone call from a social worker on the 

morning of the planned discharge. According to the complainant, the patient arrived 

 

5

 This is a treatment with a device for the administration of inhaled medications. 

6

 Aspirate is the inhalation of food, stomach contents, or other foreign matter into the airway. 

7 Failure to thrive is a gradual physical decline accompanied by apathy and a loss of willingness to eat or drink.
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

VA Office of Inspector General 4 

home by wheel chair van with only a can of Ensure8 and thickening powder. The 

complainant reported that no medications (including antibiotics) or printed discharge 

instructions were sent home with the patient; however, the medication arrived by mail 3 

days later. 

The Joint Commission requires that a patient's family be involved in decision making or 

ongoing care and provided information regarding a patient's discharge.9

 Also, VHA 

requires that staff provide discharge instructions to patients and/or caregivers and 

document such in the medical record.10 We found that staff did not involve the 

complainant who was the caregiver and POA in the July discharge planning process or 

provide complete and timely discharge instructions and medications to the patient and his 

son. 

Issue 3: Communication Between the Attending Hospitalist and Family 

We substantiated the allegation that the hospitalist did not adequately communicate with 

the complainant about the patient’s care during July 2010. Although staff often spoke to 

the patient’s daughter about her father’s medical progress, we found that most were not 

aware that the complainant was the POA and caregiver. 

Approximately 1 month after the patient’s discharge, a meeting was set up with the 

medical center’s staff and the complainant to discuss problems with patient care. The 

hospitalist who cared for the patient was present at the meeting along with the Chief of 

Staff and other managers. The hospitalist apologized for not communicating with the 

complainant and explained that he had not contacted the complainant because he held 

discussions with the patient’s daughter regarding the patient’s medical progress. The 

hospitalist was not aware that the complainant was the patient’s POA to handle the 

patient’s medical affairs and assumed that the daughter would be able to make these 

decisions. 

After the meeting, the patient was re-admitted to the medical center. During our site 

visit, the complainant told us that the communication with the hospitalist had improved 

and that he was satisfied with his father’s subsequent treatment and long term care plans. 

Issue 4: Medical Center Managers Response to Complainant’s Concerns 

We did substantiate the allegation that the medical center managers did not promptly 

respond to the complainant’s concerns; however, managers took appropriate actions once 

they became aware of the lapse in communication. 

 

8

 Ensure is an oral nutritional supplement. 

9

 JC Hospital Standard: PC.04.01.05. 

10 VHA Handbook 1907.01, Health Information Management and Health Records, August 26, 2006. 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

VA Office of Inspector General 5 

The complainant alleged that he attempted, without success, to contact medical center 

managers several times during and after the patient’s July admission to discuss concerns 

about treatment and care. The medical center managers reported they were not aware of 

the complainant’s concerns until they received a letter from Senator Webb’s office. Once 

this complaint was communicated to medical center managers; the Chief of Staff, 

Hospitalist, Home and Community Care Manager, and the complainant met in August 

2010 to discuss and resolve the concerns about the patient’s care. During our site visit, 

the complainant told us that communication and the patient’s care were improved after 

medical center managers met with him and took actions to correct the issues. 

We determined that efforts to improve communication between medical center managers, 

clinical staff, and the complainant were effective. 

Recommendation 

Recommendation: We recommended that the Medical Center Director ensure that 

medical center staff conduct discharge planning activities according to requirements and 

provide timely and complete written discharge instructions to patients and family 

members. 

Comments 

The VISN and Medical Center Directors agreed with the findings and recommendations 

(see Appendixes A and B, pages 6–8, for the Directors’ comments). The implementation 

plans are acceptable, and we will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

Appendix A 

VISN Director Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum

Date: January 31, 2011 

From: Director, VA Mid-Atlantic Health Care Network (10N6) 

Subject: Healthcare Inspection – Alleged Issues with Quality of 

Patient Care and Communication Hampton VA Medical 

Center Hampton, Virginia

To: Director, Baltimore Office of Healthcare Inspections (54BA) 

Thru: Director, Management Review Service (10B5) 

I concur with the response by the Medical Center Director, 

and with the recommendation for improvement identified in 

the report. 

 (original signed by:) 

Daniel F. Hoffmann, FACHE 

VA Mid-Atlantic Health Care Network Director, VISN 6 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 7 

Department of 

Veterans Affairs Memorandum 

Date: January 31, 2011 

From: Director, Hampton VA Medical Center (590/00) 

Subject: Healthcare Inspection – Alleged Issues with Quality of Patient 

Care and Communication Hampton VA Medical Center 

Hampton, Virginia

To: Director, VA Mid-Atlantic Health Care Network (10N6) 

1. This is to acknowledge receipt and thorough review of the 

draft report, Healthcare Inspection: Issues with Quality of 

Patient Care and Communication. I concur with the 

recommendation for improvement identified in the report. 

2. The response and action plan for the recommendation are 

enclosed. 

3. Should you have any questions regarding the comments or 

implementation plan, please contact me at 

(757) 722-9961, extension 3100. 

(original signed by:) 

Deanne M. Seekins 

Hampton VA Medical Center Director 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

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 Recommendation

Recommendation 1. We recommended that the Medical Center Director 

ensure that medical center staff conduct discharge planning activities 

according to requirements and provide timely and complete patient 

instructions to patients and family members. 

Concur Target Completion Date: May 12, 2011

Facility’s Response: 

The discharge planning process surrounding this incident was reviewed by 

the Acute Medicine Interdisciplinary Treatment Team. Based on the 

assessment of the current discharge planning process, it was determined 

that the discharge process did not include a mechanism that would ensure 

that the hospital provides timely and complete written discharge 

instructions to the patient and/or the patients family in a manner that they 

can understand. A discharge planning worksheet was developed by the 

team to improve compliance with the Joint Commission’s requirement that 

the patient or next of kin/family/caregiver is involved in the decisionmaking/treatment-planning and ongoing care, and to provide information 

regarding the patient’s discharge. The worksheet serves as a 

checklist/verify reminder indicating the set criteria to ensure continuity of 

quality patient care. 

A discharge planning worksheet for each patient is monitored by the Acute 

Medicine Nurse Manager during the daily discharge planning rounds and 

analyzed monthly by the chair of the Social Work Professional Committee 

for trends and opportunities for improvement. A summary is reported to 

the Social Work Professional Committee and acted upon. The Medical 

Executive Board will monitor quarterly for 1 year. First report is due to the 

Medical Executive Board on May 12, 2011. 

Status: Open

VA Office of Inspector General 8 
Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Donald Braman 

Baltimore Office of Healthcare Inspections 

Acknowledgments Jennifer Christensen 

Myra Conway 

Melanie Cool 

Nelson Miranda 

VA Office of Inspector General 9 
Alleged Issues with Quality of Patient Care and Communication, Hampton VA Medical Center, Hampton, VA

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Health Care Network (10N6) 

Director, Hampton VA Medical Center, Hampton, Virginia (590/00) 

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: Mark R. Warner, Jim Webb 

U.S. House of Representatives: Robert Wittman, Scott Rigell, and Bobby Scott 

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

VA Office of Inspector General 10