Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Poor Quality of Patient Care 

Marion VA Medical Center 

Marion, Illinois 

Report No. 10-03080-124 March 16, 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) 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Executive Summary 

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

to determine the validity of allegations that six patients received poor care at the Marion

VA Medical Center (the facility). Complainants reported these allegations to Senator

Richard Durbin.

We interviewed complainants, family members, managers, clinicians, and administrative

staff, and consulted with a board-certified radiologist. We also reviewed Veterans Health

Administration (VHA) directives, medical records, policies, procedures, and

documentation of fee basis care.

For three patients we identified no lapses in quality of care. However, for the remaining

three patients we identified deficiencies. For one patient the diagnosis of lung cancer was

delayed due to the misinterpretation of chest x-ray findings. A second patient had poor

coordination of diabetes care and the facility had insufficient procedures established for

operation of its telephone call center. The third patient had poor management of pain

during and after a visit to the facility emergency room (ER); however, we did not

substantiate an allegation that there was mismanagement of a hip fracture.

We recommended that the facility Director: 1) obtain a peer review assessment of the

care provided by radiologists interpreting chest x-rays for the patient with lung cancer; 2)

monitor hospital discharges to ensure that patients have ongoing coordination of care; 3)

establish telephone call center procedures in accordance with VHA policy; and 4)

monitor ER pain management to ensure compliance with VHA policy. The VISN and

facility Directors agreed with our findings and recommendations. The actions taken are

acceptable.

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 – Alleged Poor Quality of Patient Care, Marion

VA Medical Center, Marion, IL

Purpose

Senator Richard Durbin’s office requested that the VA Office of Inspector General (OIG)

Office of Healthcare Inspections (OHI) conduct a review to determine the validity of

allegations that patients received poor medical care at the Marion VA Medical Center

(the facility). Complainants had contacted Senator Durbin alleging poor care at the

facility.

Background

The facility provides services to about 44,000 Veterans residing in southern Illinois,

southwestern Indiana, and northwestern Kentucky. Part of Veterans Integrated Service

Network (VISN) 15, the facility has 55 acute care beds and a 60 bed community living

center.

In June and August 2010, OHI received the following separate allegations addressed to

Senator Durbin regarding concerns about medical care at the facility:

1. Delay in diagnosis of lung cancer due to a change in primary care providers,

absence of clinical oversight for a year, and failure to send primary care

appointment letters

2. Inadequate management of a nose lesion and mismanagement of chest pain that

required coronary stent placement

3. Poor coordination of care for diabetes

4. Poor pain management and mismanagement of a broken hip

5. Immediate death after discharge from the facility

6. Missed diagnosis of pulmonary embolism

Two additional allegations were received but not addressed in this report. One involved a

human resources issue for a non-veteran employee. The other allegation was previously

VA Office of Inspector General 1 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

evaluated by the Veterans Health Administration (VHA) Office of the Medical Inspector

and several lapses in quality of care were substantiated.

Scope and Methodology

We conducted a site visit August 24–26, 2010, interviewed complainants, family

members, managers, clinicians, and administrative staff, and consulted with a boardcertified radiologist. We reviewed VHA directives, medical records, policies,

procedures, and fee basis care documentation.

This review was performed in accordance with Quality Standards for Inspection and 

Evaluation published by the President’s Council on Integrity and Efficiency.

Inspection Results

Patient 1

Case Review 

The patient had chronic obstructive pulmonary disease (COPD) and post-traumatic stress

disorder. At primary care encounters from August 2006 through May 2008, a primary

care physician found his medical condition to be stable. The physician recommended

follow-up appointments every 6 months. A nurse practitioner (NP) assumed care of the

patient after the physician transferred to a different clinical service. In

late October 2008, the NP documented that the patient denied increased shortness of

breath and cough, and recommended continued follow-up appointments every 6 months.

In April 2009, primary care administrative staff mailed the patient three letters reminding

him to schedule a follow-up appointment. The patient did not respond, and in June staff

ordered a chest x-ray and scheduled an appointment for July. The chest x-ray, completed

in late-July, showed stable COPD and was felt to reveal no new abnormalities.

In mid-August, a different primary care physician assessed the patient. The physician

documented that the patient complained of back pain and that they discussed results of

the recent chest x-ray. The physician recommended follow-up in 6 months.

In late October, the patient presented to the primary care clinic for an unscheduled visit.

A provider documented that he was complaining of “cough for 2 weeks, sometimes

productive of yellow sputum” and prescribed an antibiotic and cough syrup. A chest

x-ray was interpreted as showing “chronic changes with questionable minimal interval

progression of interstitial infiltrative disease in left upper lobe.”

VA Office of Inspector General 2 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

In early December, the patient presented to the emergency room (ER) with productive

cough and fever. A diagnosis of pneumonia was made and he was discharged home with

an antibiotic and instructions to be re-evaluated in 1–2 weeks. A chest x-ray was

interpreted as showing persistence of “bilateral asymmetric interstitial and nodular

infiltrate/lung markings.”

Seventeen days later, during follow-up evaluation in the primary care clinic, a physician

ordered a computerized tomography (CT) scan of the chest. The CT scan, completed

three weeks later, showed a large mass encasing the left pulmonary artery. CT-guided

biopsy of the left upper lobe performed at a local hospital in early February2010 revealed

squamous cell carcinoma. Magnetic resonance imaging showed brain metastasis and an

abdominal CT scan showed mass lesions in the kidneys. One month later, palliative

radiation therapy was initiated. The patient died 2 months later.

Issue 1: Delay in cancer diagnosis

Although three chest x-rays over a 5-month period were interpreted as showing no

significant changes from previous studies, we found that in fact x-ray evidence of cancer

was present on the second of those studies. We noted that interpreting radiologists

compared diagnostic images only to the most recent previous images, thereby increasing

the probability that gradual changes over time would not be appreciated. On the second

study during the 5-month period, however, the chest x-ray was clearly abnormal and

should have prompted definitive management. When extensive disease was discovered

on a CT scan 10 weeks later, appropriate care was initiated. We were unable to

determine the impact of this delay on the patient’s clinical course.

Issue 2: Lack of clinical oversight and failure to send appointment reminder letters

We did not substantiate these allegations. Except for one 10-month period, the patient

had clinic appointments at 6-month intervals. Providers from the same primary care team

evaluated the patient and documented that his condition appeared to be stable.

Facility staff provided documentation that three letters were mailed reminding him to

schedule an appointment. When the patient did not respond, staff mailed a letter with an

appointment date. Because the patient came to the primary care clinic for this

appointment and also had scheduled visits at other clinics, we concluded that the patient

was receiving care.

VA Office of Inspector General 3 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Patient 2

Case Review 

The patient has a history of gastroesophageal reflux disease, hyperlipidemia,1 and

hypertension. He has been treated by a private physician in the community, visiting the

facility for limited care and for medications.

In mid-July 2009, the patient presented to the primary care clinic for an “area [on] his

nose he wants looked at.” A physician documented, “no lesion detected.” Two months

later, staff documented receiving medical records indicating that a non-VA dermatologist

had evaluated the patient and applied liquid nitrogen to the nose for actinic keratosis.2

In late October, the patient had a scheduled appointment with a new physician. The

physician documented that the patient reported no chest pain, palpitations, or dizziness.

The physician noted that the cardiac exam was normal and recommended follow-up in

1 year.

Two months later, clinic staff documented receiving medical records from the patient’s

private physician stating that the patient had undergone a percutaneous coronary

intervention with stent placement at a private medical facility.

Issue 1: Inadequate management of a nose lesion

We neither substantiated nor refuted this allegation. In mid-July 2009, the patient

presented to the primary care clinic with a complaint of a nose lesion. The provider

examined the patient’s nose and felt that no abnormality was present. Approximately

6 weeks later, a non-VA dermatologist treated the patient for a precancerous nose lesion.

Issue 2: Mismanagement of chest pain that resulted in surgical stent placement

We neither substantiated nor refuted this allegation. The patient received care in the

private sector and came to the facility for medications. The patient told us that during a

primary care visit for medications, he told a physician that he was having exertion-related

chest pain. The patient said that he felt the physician did not listen to his complaints.

The physician documented that the patient denied having chest pain and that the cardiac

assessment was normal.

1 High lipid (fat) levels in the blood. 2 Rough, scaly patches of skin caused by sun exposure and considered to be precancerous. 

VA Office of Inspector General 4 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Patient 3

Case Review 

The patient had a history of diabetes and coronary artery disease. He had undergone

coronary artery bypass surgery in 2008.

In mid-March 2009, the patient was admitted to the facility with poorly-controlled

diabetes and an infection involving his left foot. After treatment with an intravenous (IV)

antibiotic, he was discharged home three days later with arrangements for daily dressing

changes by a community home health (HH) care agency. On the day of discharge, the

patient’s last recorded blood glucose was 400 milligrams per deciliter (mg/dl).3 Several

hours after discharge, the patient’s mother called the inpatient medical unit and reported

that the patient’s blood glucose was in the 30–40 mg/dl range. A staff nurse advised the

mother to take the patient to the nearest ER.

The next day, HH staff completed an initial home visit and two days later the VA

community health nurse documented that HH agency goals for the patient were to

improve diabetes compliance, decrease smoking, and initiate a home exercise program.

The next day, the facility community health nurse approved 15 home visits.

Six days after discharge, a caregiver contacted the facility’s telephone call center and

reported that the patient’s blood glucose ranged from 78 to 400 and that he was having

episodes of dizziness and sweating. The call center nurse advised the caregiver about

using insulin to treat this patient and recommended that the patient eat every 3–4 hours.

Based on a computerized clinical decision support tool, the call center nurse

characterized the patient’s condition as “urgent” and recommended follow-up care in the

clinic. The nurse’s note indicates that the caregiver declined for the patient to return to

the facility at that time. The nurse sent the call center note to two physicians with a

request for receipt acknowledgement.

On the next day (7 days after discharge), HH staff completed a second visit and

discharged the patient from care because of non-compliance. Facility staff were unaware

that HH visits were not continuing. The patient died 2 days later.

Issue 1: Poor coordination of diabetes care

We substantiated this allegation. The patient was discharged with marked

hyperglycemia. The facility approved 15 HH visits, but after 2 visits HH care was

discontinued due to patient noncompliance. VA staff were unaware that HH had

discontinued care. The HH agency documented that the patient was discharged from care

3 The normal range for blood glucose is 70–100 mg/dl.

VA Office of Inspector General 5 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

on the seventh day after he was discharged from the facility, but the VA community

health nurse documented on the tenth day after discharge that HH care was ongoing.

A patient caregiver called the facility with concerns about unstable blood glucose values.

The call center nurse recommended follow-up care at the facility, but the caregiver

declined.

Issue 2: Lack of standard procedures in telephone call center

We assessed processes in the telephone call center, noting that VHA policy4 requires an

annual review of clinical decision support tools used in call centers. We found that the

facility had no established procedure for determining how soon ‘urgent’ patients need to

be evaluated and did not specify the expected level of involvement of primary care

providers.

Patient 4

Case Review 

The patient is an elderly man with COPD, hypertension, and Alzheimer's dementia.

In late May 2009, the patient fell at home and his family drove him to the facility’s ER.

The patient was noted to be in severe pain (10/105

), but an x-ray of the left hip showed no

fracture. Staff instructed the patient to use a walker and take acetaminophen as needed

for pain.

On the following day, the patient’s family drove him back to the ER because of persistent

severe pain. The patient's wife reported that he complained of knee, not hip, pain and

that he was unable to stand. She said that she could not take care of him and requested

nursing home placement. The ER staff documented that the patient was alert and

oriented and that the intensity of his pain was 8 out of 10. An x-ray of the left knee

showed no fracture or dislocation. The patient was admitted for pain management and

nursing home placement. During the 4-day inpatient stay, staff documented that the

patient moved all extremities well and ambulated 70 feet with a walker and assistance.

At the time of transfer to a local nursing home, the patient denied pain.

Eight days after discharge, a private medical center reported that the patient had

presented to its ER with right hip pain and was found to have a right hip fracture. The

medical center’s staff informed facility utilization review staff that the patient’s wife

reported that he had several recent falls.

4 VHA Directive 2007-033, Telephone Service for Clinical Care, October 11, 2007. 5 0 = no pain. 10 = worst imaginable pain.

VA Office of Inspector General 6 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Issue 1: Poor pain management

We substantiated this allegation. During his initial ER evaluation, the patient had severe

pain, but was discharged to home and treated with only acetaminophen. When he

returned to the ER on the following day, he was admitted for management of severe pain

and for nursing home placement.

Issue 2: Inadequate management of hip fracture

We did not substantiate this allegation. At initial presentation, the patient had left leg

pain, but x-rays showed no fracture. While hospitalized, he moved all extremities well

and was able to walk with assistance, and he denied pain at the time of discharge. The

facility was notified 8 days after discharge that the patient had presented to a private

hospital with right hip pain and was found to have a right hip fracture.

Patient 5

Case Review 

The patient had a history of hypertension, diabetes, coronary artery disease, aortic

stenosis, and congestive heart failure (CHF). He had undergone coronary bypass surgery

approximately 15 years earlier.

The patient was hospitalized at the facility in late 2005 for management of abdominal

pain. Four months prior to admission, echocardiography had shown severe aortic

stenosis and markedly depressed left ventricular function. Ultrasonography of the upper

abdomen showed no significant abnormalities of the gallbladder or liver. He was treated

with diuretics to reduce fluid retention attributed to CHF and gradually improved.

However, generalized weakness continued and he was able to walk only short distances.

Short-term nursing home placement was declined.

On hospital day 11, the patient denied abdominal pain, reported feeling better, and was

discharged to the care of his son. The discharging physician assessed the patient to be

medically stable. Eleven days after discharge, staff documented that the son had called to

report that the patient died soon after arriving home on the day of discharge.

Issue: Immediate death after discharge

We found no evidence that poor quality of care led to the patient’s death soon after

discharge from the facility. The patient had multiple medical problems, including severe

aortic stenosis and CHF. Because the patient’s heart disease caused marked generalized

weakness, nursing home placement was recommended. However, the patient’s son

VA Office of Inspector General 7 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

requested to take him home. The son told us that the patient collapsed and died soon

after arriving home.

Patient 6

Case Review 

The patient is an elderly man with COPD and a remote history of colon cancer.

He presented to the ER with complaints of shortness of breath on exertion, productive

cough, and mid-back pain that occurred with coughing, deep breathing, and movement.

He had no fever, but did have an elevated white blood cell count and oxygen saturation

by pulse oximetry of 92 percent while breathing room air. A chest x-ray showed chronic

changes consistent with COPD. He was admitted to the medical unit with a diagnosis of

COPD exacerbation with bronchitis and treated with IV antibiotics. On admission his

oxygen saturation was 96 percent with the use of supplemental oxygen.

While hospitalized, the patient was treated with anticoagulants for the prevention of

venous thromboembolism. A non-contrast chest CT scan showed only COPD; blood

cultures had no growth after 5 days. His condition gradually improved and he was

discharged home after 8 days with oxygen saturation 97 percent on room air.

Seventeen days after discharge, the patient presented to the ER with rectal bleeding and

recurrent shortness of breath. A physician documented that the patient had a respiratory

rate of 18, normal heart and lung examinations, and oxygen saturation 96 percent on

room air. The chest x-ray showed no new abnormalities. The patient received IV fluids

and was given a referral for gastroenterology consultation. He was discharged home with

an antibiotic and instructions to rest and increase fluid intake.

Three days later the patient presented to a private medical facility where he was

hospitalized and CT angiography revealed pulmonary embolism (PE).6

Issue: Missed diagnosis of PE

We did not substantiate this allegation. The patient was admitted to the hospital for an

exacerbation of COPD and gradually improved on antibiotics. While hospitalized, he

received anticoagulants for prevention of venous thromboembolism. Providers told us

that on both occasions when he presented to the ER, he was not considered to be at

increased risk for PE because of the absence of typical signs, symptoms, or risk factors.

Providers reported that CT angiography for the possibility of PE was not done because

6 Pulmonary embolism is the obstruction of blood vessels in the lungs by material travelling from elsewhere in the

circulatory system, most commonly from blood clots in the legs.

VA Office of Inspector General 8 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

the patient had impaired kidney function,7 but this consideration was not mentioned in

documentation by any provider.

This patient’s care might have been improved if physicians had chosen to pursue the

diagnosis of PE at initial presentation, including the option to perform lower extremity

ultrasonography for possible deep vein thrombosis.8 However, the absence of typical

findings (risk factors, signs and symptoms, and persistent or marked oxygen desaturation)

suggests that providers acted within the range of acceptable clinical practice.

Conclusions

Patient 1 had regular visits in the same primary care clinic and had numerous chest x-rays

that were stable. When the patient had persistent symptoms, clinicians ordered a CT scan

which revealed cancer. Review of the patient’s x-rays revealed that the cancer had been

evident on a chest x-ray 10 weeks before the CT scan.

Patient 2 visited a facility primary care physician complaining of a nose lesion. The

physician examined the patient and judged that no abnormality was present. Although a

non-VA dermatologist subsequently treated the patient for a precancerous lesion, we

could not evaluate the appropriateness of that treatment. We were unable to determine

whether this patient reported chest pain symptoms to physicians or that there was any

delay in treatment of his heart disease.

Patient 3 had poor coordination of his diabetes care and the facility had insufficient

procedures established for operation of its telephone call center.

Patient 4 had poor management of pain during and after his initial ER visit. He rated his

pain as 10/10 (the worst possible pain), but received no effective treatment for pain and

was discharged to home. However, we did not substantiate an allegation that there was

mismanagement of a hip fracture.

Patient 5 was hospitalized with severe cardiovascular disease. He died within hours of

discharge from the facility, but we identified no lapses in quality of care.

Patient 6 was found to have pulmonary embolism when he presented to a private hospital

3 days after evaluation at the facility. We found that care provided at the facility was

within the range of acceptable clinical practice.

7 Angiography requires the use of IV contrast material, which can damage the kidneys and is avoided when possible

in patients with compromised kidney function.

8 In most cases, PE arises from deep vein thrombosis (blood clots) in the legs. Detection of these clots would

support the diagnosis of PE and prompt treatment with long-term anticoagulation at doses higher than what is used

for prevention.

VA Office of Inspector General 9 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Recommendations

Recommendation 1. We recommend that the VISN Director require that the facility

Director obtains a peer review assessment of the care provided by radiologists

interpreting chest x-rays for Patient 1.

Recommendation 2. We recommended that VISN Director require that the facility

Director monitors hospital discharges to ensure that patients have ongoing coordination

of care.

Recommendation 3. We recommended that the VISN Director require that the facility

Director establish telephone call center procedures in accordance with VHA policy.

Recommendation 4. We recommended that the VISN Director require that the facility

Director monitor ER pain management to ensure compliance with VHA policy.

Comments

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

and B, pages 12–14, for the full text of their comments and completed actions). We

consider Recommendation 1 closed. We will follow up on the planned actions for

Recommendations 2–4 until they are completed.

 (original signed by:) 

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 10 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date:	 March 2, 2011

From:	 Director, VA Heartland Network (10N15)

Subject:	 Healthcare Inspection – Alleged Poor Quality of Patient Care,

Marion VA Medical Center, Marion, IL

To:	 Director, Kansas City Office of Healthcare Inspections

Thru:	 Director, Management Review Service (10B5)

I have reviewed this report and the recommendations. First, I would

like to thank the Kansas City Office of Inspector General (OIG)

Office of Healthcare Inspections (OHI) team for the time and

attention they took to review these events, that occurred, in some

cases two or three years ago. Retroactive reviews such as this

present unique challenges and the efforts of the OIG/OHI team to be

thorough and fair in their review deserves recognition.

Second, I want to emphasize the efforts that the Medical Center took

proactively to address the issues since 2009 and also highlight

actions that have been taken more recently in response to the report

recommendations.

The OIG report indicates that the diagnosis of lung cancer in one

patient may have been delayed because of a possible

misinterpretation of chest x-ray findings. It is important to note that

prior to the OIG review the Medical Center determined the situation

warranted an independent peer review assessment of the care

provided by radiologists interpreting chest x-rays. The peer review

process has been completed with the determination that the

appropriate standard of care was met.

VA Office of Inspector General 11 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL

In April 2009, the Medical Center implemented an Inpatient Case

Management program to address; difficulties with monitoring

hospital discharges, and coordination of care.

To address the issues identified by the OIG team regarding the handoff process between the call center and the Primary Care Provider,

the Medical Center is updating its procedures and expects to

implement these no later than March 2011.

The event related to management of pain in the Emergency Room

occurred in May 2009. In October 2009, the Medical Center

implemented additional monitoring to assess if pain was being

assessed in the Emergency Department and if treatment of the pain

was initiated in the Emergency Department. The facility has been

regularly monitoring pain management in the Emergency

Department since that time.

Reviewing prior situations is important to inform future actions.

Accordingly, we concur with the report recommendations and will

continue to ensure that the Medical Center addresses these concerns.

JAMES R. FLOYD, FACHE

VA Office of Inspector General 12 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Appendix B

Facility Center Director Comments

Department of

Veterans Affairs Memorandum

Date: March 3, 2011 

From: Director, Marion VA Medical Center, Marion, IL (657A5/00) 

Subject: Healthcare Inspection – Alleged Poor Quality of Patient Care, 

Marion VA Medical Center, Marion, IL

To: Director, VA Heartland Network 15 (10N15)

An OIG visit was conducted August 24–26, 2010, in response to six

Veteran’s concerns. Enclosed is the response to the

recommendations.

Paul Bockelman 

VA Office of Inspector General 13 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Director’s Comments 

to Office of Inspector General’s Report 

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

recommendation in the Office of Inspector General’s report:

OIG Recommendations

Recommendation 1. We recommend that the VISN Director require

that the facillity Director obtain a peer review assessment of the care

provided by radiologists interpreting chest x-rays for Patient 1.

Concur Target Completion Date: Closed

Prior to the OIG review, leadership at the VAMC Marion determined that

an independent peer review assessment of the care provided by radiologists

interpreting the chest x-rays for Patient 1 was warranted. Leadership then

convened a review. The results of the review indicated that the standards of

care had been met, and this review has been shared with the OIG.

Leadership at VAMC continues to pursue effective utilization of the peer

review process to improve care for Veterans. The peer review process and

requirements for the facility are stated in Medical Center Memorandum

(MCM) 00-00QM-10-587 Peer Review Program. This MCM is based on

the VHA Directive 2010-025, Peer Review for Quality Management. A

monitor related to peer reviews conducted at VAMC Marion is in place so

that leadership can continuously evaluate the volume and results of peer

reviews as well as analyze the data for trends.

Recommendation 2. We recommended that the VISN Director require

that the facility Director monitor hospital discharges to ensure that patients

have ongoing coordination of care.

Concur Target Completion Date: Closed

This event occurred in March 2009 and was addressed by the

Medical Center in April 2009 with the implementation of an

inpatient case management program. This program included the

hiring of three Registered Nurse (RN) Discharge Planning Case

Managers and an increase in Community Health Nurses from one to

six full-time positions in January 2010.

VA Office of Inspector General 14 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL

A Standard Operating Procedure has been developed and implemented

outlining the process used by the Inpatient Case Managers to facilitate the

coordination of care with the Primary Care Clinic Staff during the

discharge process. In addition, a monitoring tool has been implemented to

assess effectiveness of this process improvement.

Recommendation 3. We recommended that the VISN Director require

that the facility Director establish telephone call center procedures in

accordance with VHA policy.

Concur Target Completion Date: Closed

While the Medical Center had established specific telephone call center

procedures, the report points out where improvements can be made. The

Medical Center has established a more effective hand-off process between

the call center and Primary Care providers. The process includes reviews to

monitor effectiveness.

Recommendation 4. We recommended that the VISN Director require

that the facility Director monitor ER pain management to ensure

compliance with VHA policy.

Concur Target Completion Date: Closed

This event related to management of pain in the emergency room occurred

in May of 2009. In November 2009, the Medical Center implemented an

Emergency Department process for monitoring the completion of pain

assessments with subsequent initiation of treatment in appropriate clinical

situations. This process has been reviewed regularly. Effective

January 24, 2011, an additional monitor has been added to assess the

effectiveness of pain treatment initiated in the Emergency Department.

VA Office of Inspector General 15 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact	 Dorothy Duncan, RN

Director, Kansas City Office of Healthcare Inspections

Acknowledgments	 James Seitz, RN Team Leader

Jerome Herbers, MD

Reba B. Ransom, RN

Jennifer Whitehead

VA Office of Inspector General 16 
Alleged Poor Quality of Patient Care, Marion VA Medical Center, Marion, IL 

Appendix D

Report Distribution 

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VA Heartland Health Care Network (10N15)

Director, VA Medical Center, Marion, Illinois (657A5/00)

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: Richard J. Durbin, Mark Kirk

U.S. House of Representatives: Jerry Costello, S. Brett Guthrie, John Shimkus,

Ed Whitfield, Todd Young

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

VA Office of Inspector General 17