Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Emergency Room Discharge 

of a Hospice Patient 

Hampton VA Medical Center 

Hampton, Virginia 

Report No. 10-04043-136 March 30, 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)
 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Executive Summary
 

In September 2010, a confidential complainant contacted the VA Office of Inspector

General Office of Healthcare Inspections (OHI) regarding a complaint concerning the

care a patient received at the Hampton VA Medical Center (facility), Hampton, VA. OHI

evaluated the validity of the following allegations:

	 The emergency room (ER) provider did not perform a complete evaluation of the

patient’s condition prior to discharging the patient home.

	 Staff treated the patient and spouse poorly during the ER visit.

	 When the patient’s spouse asked facility staff to admit the patient to the hospice

unit or hospital, the staff informed the spouse that the patient did not meet criteria

for hospital admission and that the hospice unit was full.

	 On the day of the ER visit, the complainant stated that a staff member told the

complainant that there were four hospice beds available.

We substantiated the allegation that the ER provider did not perform a complete

evaluation of the patient during his last ER visit. Review of the records indicated there

were other possible causes for the patient’s condition that were not evaluated. The ER

provider’s note did not assess the veteran’s functional status. Better awareness of this

deficit may have prevented some of the difficulties this veteran experienced.

Additionally, when the patient arrived home after leaving the VA ER, paramedics

transported the patient to a non-VA hospital where an ER provider admitted the patient.

We could not confirm or refute the allegation that the staff treated the patient and spouse

poorly. We did not substantiate the allegation that hospice beds were available on the

day of the patient’s last ER visit. We substantiated the allegation that the patient was not

provided hospice care when requested. The Palliative Care Consult Team (PCCT) did

not see the patient when informed that the family requested their services nor help to

facilitate the hospice care process. During our interviews, we asked staff if they were

aware of VA hospice guidelines and with the exception of PCCT members, staff denied

knowledge of the directive or requirements. Facility staff missed numerous opportunities

to initiate hospice care services earlier in the patient’s course of treatment.

We recommended that all ER staff receive training in hospice and palliative care related

to patients with advanced life-limiting diseases, the facility put in place methods that

actively seek patients needing hospice and palliative care, and the facility provides

hospice and palliative care education activities for all clinical staff.

The VISN and facility Directors agreed with our findings and recommendations. The

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

they are completed.

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 – Emergency Room Discharge of a Hospice

Patient, Hampton VA Medical Center, Hampton, Virginia

Purpose

In September 2010, a confidential complainant contacted the VA Office of Inspector

General (OIG) Office of Healthcare Inspections (OHI) regarding a complaint concerning

the care a patient received at the Hampton VA Medical Center (facility), Hampton, VA.

OHI evaluated the validity of the allegations of poor customer service and that a provider

inappropriately discharged a patient from the emergency room (ER) at the facility. The

purpose of the inspection was to determine if the allegations had merit.

Background

The facility provides acute care in primary, specialty, and long-term care services. The

facility is part of Veterans Integrated Service Network (VISN) 6 and serves a veteran

population of about 220,000 throughout 15 counties in eastern Virginia and 10 counties

in northeastern North Carolina. The 468-bed facility provides comprehensive healthcare

through primary, acute inpatient, psychiatric, chronic spinal cord injury, long-term,

domiciliary rehabilitative residential, and hospice and palliative care.

The goal of hospice and palliative care (HPC) is to improve end-of-life care by enhancing

the quality of life for the terminally ill and their loved ones. It is a team-oriented

approach that includes medical care; pain management; and emotional, social, and

spiritual support. HPC care teams can provide in-home or inpatient care for people

diagnosed with an incurable disease with less than 6 months to live. Hospice care

focuses on enhancing the quality of life remaining for patients by providing care 24 hours

a day, 7 days a week. In addition, hospice care includes bereavement and counseling

services to surviving family and friends. Hospice care strives to allow patients to die

with dignity, pain-free.1

1 National Hospice and Palliative Care Organization, www.nhpco.org, accessed October 15, 2010.

VA Office of Inspector General 1 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

The Veterans’ Health Care Eligibility Reform Act2 mandates facilities provide hospice

services to all veterans meeting hospice criteria. The facility should provide in-home or

inpatient hospice care. Hospice services should be readily available to the patient. For

facilities that cannot provide inpatient hospice care, community inpatient hospice will

provide care. All facilities should assemble a Palliative Care Consult Team (PCCT) to

ensure veterans with serious, life limiting illnesses have hospice and palliative care

services available. The VISN director should encourage PCCTs to have service

agreements with departments in the facility that generate referrals.3

The complainant alleged that a facility provider inappropriately discharged a patient from

the ER when requesting admission for hospice care. The complainant specifically

alleged that:

	 The ER provider did not perform a complete evaluation of the patient’s condition

prior to discharging the patient home.

	 Staff treated the patient and spouse poorly during the ER visit.

	 When the patient’s spouse asked facility staff to admit the patient to the hospice

unit or hospital, the staff informed the spouse that the patient did not meet criteria

for hospital admission, and that the hospice unit was full.

	 On the day of the ER visit, the complainant stated that a staff member told the

complainant that there were four hospice beds available.

Scope and Methodology

We interviewed the complainant and patient’s spouse by telephone prior to the site visit

October 25–26, 2010. While onsite, we interviewed managers, clinicians, and other staff

pertinent to the complaints. We reviewed the patient’s medical record, relevant facility

and Veterans Health Administration (VHA) policies, as well as a peer review of the case.

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 Summary

The complaint concerned the care of a service connected male in his fifties, who

transferred care to the facility in August 2010 after previously receiving treatment from

private care providers. Non-VA physicians diagnosed the patient with lung cancer with

metastasis4 to the brain in January 2010 and treated the patient with chemotherapy and

2 Public Law 104-262 [HR 3118], Veterans’ Health Care Eligibility Reform Act of 1996, October 9, 1996.

3 VHA Directive 2008-066, Palliative Care Consult Teams (PCCT), October 23, 2008. 4 Metastasis is the spread of a disease in an individual, from one organ or part to another non-adjacent organ or part.

VA Office of Inspector General 2 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

radiation. The patient’s medical history included low blood cell counts and a recent

pulmonary embolism for which the patient was taking blood-thinning medication.

In August 2010, the patient presented to the facility’s ER to establish care and obtain

refills on medications. The ER provider and a mental health provider filled the

medications and documented the patient’s current mental and physical status including

high risk for falls. The patient’s speech was coherent and relevant, thoughts were

organized and goal directed, and insight and judgment were good. The patient required a

walker for mobility. During this visit, the patient had a follow-up primary care

appointment scheduled for early September 2010.

Nine days later, the spouse brought the patient to the facility’s ER with complaints of

pain, weakness, and change in mental status over the previous 5 days. The ER provider

admitted the patient for 23-hour medical observation. Once admitted, further testing

showed the patient’s blood to be too thin and possible bleeding in the brain. The

attending physician converted the patient’s admission to an acute care admission. The

physician temporarily stopped the patient’s blood thinning medication and gave the

patient medication to reverse the blood thinning effects. Based on the patient’s medical

history, and signs and symptoms, the physician deemed the possibility of bleeding in the

brain to be minimal. During the 2-day hospitalization, the patient’s pain was treated,

weakness resolved, and a follow-up appointment with hematology-oncology was

scheduled.

Three days later, a primary care clinic case manager called the patient’s home and spoke

to the spouse. Documentation revealed that during this call the patient’s spouse asked

about home hospice care. The case manager did not submit a hospice referral, but

documented it could be done at either the primary care provider or oncologist

appointments within the next 2 weeks.

Six days later, the patient’s spouse brought the patient back to the ER stating the patient

had fallen twice and now had altered mental status. The spouse required assistance from

the ER staff to get the patient out of the car; the patient could not use the walker and

required a wheelchair to get into the facility. Documentation revealed that the patient

was weak with altered mental status and listed the patient’s triage level as level II,

imminent.5 During the ER visit, the patient was confused, incontinent, attempted to get

out of bed without required assistance, and the spouse requested an evaluation of the

patient’s condition and palliative care. The provider’s progress note listed the patient’s

chief complaint as confusion. The provider was unable to get a history from the patient

and the progress note stated the family was not available. The provider documented the

lung exam as normal, neurologic exam as grossly intact, and motor strength as normal.

The provider documented the laboratory results as stable, and the chest x-ray showed

5 This condition is a potential threat to life, limb, or function and requires rapid medical intervention.

VA Office of Inspector General 3 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

possible pneumonia or collapsed lung. The provider treated the patient with an

intravenous antibiotic for pneumonia.

Documentation showed the provider determined the patient did not met criteria for an

acute care admission to the facility. Because the spouse had requested palliative care, the

provider contacted a coordinator to assist the family. The coordinator’s documentation

noted that the spouse was having difficulty managing the patient at home and could no

longer provide care in the home, the spouse understood the patient was terminal and

hospice care only provides comfort care, and there were no hospice care beds available.

The coordinator arranged facility community living center admission for the next

morning and the patient’s spouse was to call a family member to assist in caring for the

patient that night. The provider discharged the patient home with oral antibiotics to treat

the pneumonia.

Once home, the spouse and a family member were unable to get the patient out of the

vehicle and had to call 911 for assistance. Paramedics transported the patient to a local

ER where the physician admitted the patient to an acute care unit. Because of the

patient’s confused mental status, the spouse provided the history. The medical record

shows that the patient had become increasingly difficult to manage at home due to falls

and confusion. The physician at the private hospital noted the family’s request for

comfort care and no resuscitation. The physician also noted the patient was eligible for

VA hospice and would transfer the patient when a bed became available. Records

documented the reason for admission as behavior, increasing combativeness and

confusion, falls, and the family’s inability to care for the patient at home.

Two days after admission to the private hospital, the VA received a request for hospice

from the private hospital physician. The PCCT submitted a palliative care consult. The

patient was scheduled to be admitted to the VA inpatient hospice unit 5 days later.

However, he died 2 days before the scheduled transfer date.

Inspection Results

Issue 1: The ER provider did not perform a complete evaluation of the patient’s

condition prior to discharging the patient home.

We substantiated the allegation that the ER provider did not do a complete evaluation of

the patient prior to discharging the patient home.

The patient had a known history of lung cancer that had metastasized to the brain. The

3 weeks prior to the last visit were notable for two ER visits and a hospital admission.

The nurse triage note on the last ER visit noted return with the same symptoms of

weakness and confusion from the prior ER visit. The ER provider’s note stated that the

history was based on the triage sheet, noting the spouse was not available for interview

VA Office of Inspector General 4 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

and the history could not be obtained from the patient; however, it did not reflect review

of the patient’s recent medical history.

The provider’s progress note did not document significant decline in the patient’s

function over the last 3 weeks as noted in the medical record, nor did it reflect exploring

complications associated with brain metastasis, blood thinning medication, and falls as

possible causes of altered mental status.

Despite the complaint of significant weakness, the patient’s physical exam, other than

altered mental status, was documented as unremarkable. The neurological examination

was noted to be grossly intact but did not document sensation, reflexes, or coordination.

There was no documentation of an assessment of the patient’s ability to transfer or walk.

The ER provider did obtain laboratory studies that had not changed significantly from

prior studies. The patient’s chest x-ray showed pneumonia which was treated with an

antibiotic. An admission to the CLC was arranged for the veteran the next morning.

Issue 2: Staff treated the patient and spouse poorly.

We could not confirm or refute the allegation that the staff treated the patient and spouse

poorly during the ER visit.

During our interview with the spouse, she stated that when they arrived at the facility’s

ER, the vehicle was valet-parked, she requested help twice, and had to wait

15 minutes for assistance. On discharge, the spouse asked for assistance to get the patient

to the vehicle. However a staff member only put the patient in a wheelchair, no one

helped get the patient to the vehicle or in the vehicle. Further, the valet who retrieved the

vehicle did not offer to assist the patient into the vehicle or offer to get someone else to

help. The spouse reported getting assistance from non-staff members to get the patient

into the vehicle.

During our interviews with facility staff, a staff member informed us that valets do not

normally assist with veteran transfers, and ER staff members always provide assistance

when asked. No one interviewed involved with the case recalls being asked to assist this

patient.

The facility leadership reported recent investments in customer care to include hiring

patient flow coordinators as care liaisons.

VA Office of Inspector General 5 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Issue 3: The facility did not provide hospice care to the patient when requested.

We substantiated the allegation that the facility did not provide hospice care to the patient

when requested.

VHA Directive 2008-066 states:

The mission of the VA HPC program is to honor the veteran’s preferences

for care at the end of life. Facilities are required to have in place a

mechanism to identify veterans who may be appropriate for HPC and

determine their specific preferences for care. Facility staff should strive to

meet veterans’ needs in the setting that best accommodates their needs and

preferences.6

The patient had an admission to the facility through the ER less than 2 weeks prior to this

ER visit. During that hospitalization, several of the staff were aware of the patient’s

condition and should have entered a consult to the PCCT. The facility had templates in

place to trigger hospice consults. However, there was no hospice consult initiated for the

patient by anyone at the facility prior to contact from the outside hospital.

At the last ER visit, the ER provider contacted a coordinator. The coordinator contacted

the PCCT to request a hospice admission that day. The team member told the

coordinator no beds were available on the hospice unit. The PCCT team member did not

make contact with the patient or initiate a hospice consult. Further, when facility staff

discovered the patient was an inpatient at an outside hospital, no one attempted to

coordinate a transfer or initiate a hospice consult. Only after the private hospital’s

physician’s request did the PCCT initiate a palliative care consult. The PCCT scheduled

the patient for admission to the facility’s inpatient hospice 5 days after the private

hospital physician contacted them. The patient died 2 days before the scheduled transfer

to the facility PCCT.

Issue 4: On the day of the ER visit, four hospice beds were available.

We did not substantiate the allegation that hospice beds were available on the day of the

patient’s last ER visit.

The facility has 10 allocated inpatient hospice beds; however, during our interview, a

staff member informed us that only 8 of the beds are active due to staffing. Review of

the gains and losses report7 for the day of the patient’s ER visit showed that patients

occupied seven of the eight beds. Staff informed us that the remaining bed was for a

patient previously scheduled for transfer from outside of the facility, who was to arrive

the following morning.

6 VHA Directive 2008-066, Palliative Care Consult Teams (PCCT), October 23, 2008. 7 The gains and losses report is the facility tracking record for daily bed usage.

VA Office of Inspector General 6 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Conclusions

We substantiated the allegation that the ER provider did not perform a complete

evaluation of the patient during his last ER visit. Review of the records indicated there

were other possible causes for the patient’s condition that were not evaluated. The ER

provider’s note did not assess the veteran’s functional status. Better awareness of this

deficit may have prevented some of the difficulties this patient experienced.

Additionally, when the patient arrived home from the VA ER, paramedics transported the

patient to a non-VA hospital where an ER physician admitted the patient.

We could not confirm or refute the allegation that the staff treated the patient and spouse

poorly. We did not substantiate the allegation that hospice beds were available on the

day of the patient’s last ER visit. We substantiated the allegation that the patient was not

provided hospice care when requested. The PCCT did not see the patient when informed

that the family requested their services nor help to facilitate the hospice care process.

During our interviews, we asked staff if they were aware of VA hospice guidelines and

with the exception of PCCT members, staff denied knowledge of the directive or

requirements. Facility staff missed numerous opportunities to initiate palliative care

services earlier in the patient’s course of treatment.

Recommendations

Recommendation 1. We recommend that the facility ensure all ER staff receive training

in hospice and palliative care related to patients with advanced life-limiting diseases.

Recommendation 2. We recommend that the facility put in place methods that actively

seek patients needing hospice and palliative care.

Recommendation 3. We recommend that the facility provides hospice and palliative

care education activities for all clinical staff.

Comments

The VISN and System Directors’ concurred with our findings. See Appendixes A and B,

pages 8–11 for the full text of their 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
 

VA Office of Inspector General 7 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date:

From:

February 24, 2011 

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

Subject:	 Healthcare Inspection – Emergency Room Discharge of a 

Hospice Patient, Hampton VA Medical Center, Hampton, 

Virginia 

To:	 Director, Operations Division, Office of Management & 

Administration (53B) 

Thru:	 Director, Management Review Service (10B5) 

Director, Washington, DC Office of Healthcare Inspections 

(54DC) 

I concur with the response by the Medical Center Director, 

and with the recommendations for improvement identified in 

the report. 

(original signed by:) 

Daniel F. Hoffman, FACHE 

VA Mid-Atlantic Health Care Network Director, VISN 6 

VA Office of Inspector General 8 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Appendix B

Facility Director Comments

Department of

Veterans Affairs Memorandum

Date:	 February 11, 2011

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

Subject:	 Healthcare Inspection – Emergency Room Discharge of a 

Hospice Patient, 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

Office of Inspector General Healthcare Inspections –

Emergency Room Discharge of a Hospice Patient draft

report. I concur with the recommendations for

improvement identified in the report.

2. The response and action plan for the recommendation is

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, MBA
 

Hampton VA Medical Center Director
 

VA Office of Inspector General 9 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

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 1: We recommend that the facility ensure all ER staff

receive training in hospice and palliative care related to patients with

advanced life-limiting diseases.

Concur Target Completion Date: March 2 and 3, 2011

Facility’s Response: 

Review of Allegation #1: Hampton VAMC is conducting a formal “End of

Life/Palliative Education Resource Center” (EPERC) on

March 2 and 3, 2011. This two-day continuous training consists of

16 modules. The course will be instructed by the Medical Director of the

Palliative Care Unit and the VISN Geriatrics Service Line Champion. The

target audience for this training is all clinicians, including physicians,

nurses, social workers, nursing assistants, chaplains, and other ancillary

services as appropriate. All Emergency, Spinal Cord Injury, and Medicine

physicians will be expected to attend.

Hampton VAMC has also developed a pocket card identifying conditions

when Palliative Consult may be considered.

These cards were distributed to Primary Care, Medicine, and Emergency

Room providers with the Medical Director of Palliative Care Unit’s phone

number available for any questions.

Status: Underway

Recommendation 2: We recommend that the facility put in place methods

that actively seek patients needing hospice and palliative care.

Concur Target Completion Date: Completed

Facility’s Response: Hampton VAMC’s Palliative Care team has

established relationships with community partners. The Palliative Care

VA Office of Inspector General 10 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

team is working toward strengthening these relationships by holding

quarterly meetings with representatives from local hospital and local home

health agencies. During these meetings, the Palliative Care team educates

the community partners on services available to Veterans and how to obtain

a Palliative Care Consult. In addition, the team provides education on how

to assist a Veteran in enrollment for VA benefits if appropriate. Printed

information and pamphlets with contact phone numbers are distributed to

the community partners for their reference.

Status: Completed.

Recommendation 3: We recommend that the facility provides hospice and

palliative care education activities for all clinical staff.

Concur Target Completion Date: March 2 and 3/ongoing

Facility’s Response: 

All clinical staff will complete the VISN6 Hospice and Palliative Care

(HPC) Training module number V06 VA 1367764 on the Learning

Management System (LMS). The HPC training requirement will be added

to each clinical staff’s training requirements in LMS.

Status: Ongoing

VA Office of Inspector General 11 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact Cathleen King, RN, Associate Director

Dallas Office of Healthcare Inspections

Acknowledgments Gayle Karamanos, PA, Team Leader

Larry Ross, MS

Maureen Washburn, RN

George Wesley, MD

Robert Yang, MD

Misti Kincaid, Program Support Assistant

VA Office of Inspector General 12 
Emergency Room Discharge of a Hospice Patient, Hampton VA Medical Center, Hampton, Virginia 

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 (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

US Senate: Mark R. Warner, Jim Webb

US House of Representatives: E. Scott Rigell, Bobby Scott, Rob Wittman

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

VA Office of Inspector General 13