Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Quality of Care Issues
 

VA Northern Indiana Health Care System
 

Fort Wayne, Indiana
 

Report No. 10-02810-139 March 31, 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 Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Executive Summary
 

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

an inspection to determine the validity of allegations regarding quality of care issues at

the VA Northern Indiana Health Care System, Fort Wayne, IN.

A complainant alleged that there was a delay in notification of test results, diagnosis, and

treatment, which may have led to multiple emergency department (ED) visits and a

subsequent hospital admission. The complainant also alleged that his complaints of

infection were ignored, and that a medication was prescribed that exacerbated his

Myasthenia Gravis (MG), a disease that affects the connection between muscles and

nerves. Additional allegations included a breach in aseptic technique during intravenous

therapy and delays in access to primary care.

We substantiated that there were delays in notification of the patient’s test results and the

diagnosis of MG, with missed opportunities for follow-up care. We found that a

neurologist was aware of abnormal test results suggestive of MG in July 2009, but he did

not inform the patient until December 2009.

We substantiated that a delay in diagnosis and treatment may have led to multiple ED

visits and a subsequent hospital admission. Multiple ED and primary care providers

between April 2009 and December 2009 saw the patient; however, aggressive treatment

for his MG was not begun until December 2009.

We substantiated that a provider prescribed an antibiotic that exacerbated the patient’s

MG. While there were clinical reasons for prescribing an antibiotic, given the known risk

of this specific medication, a more extensive search for a safer medication or a more

detailed discussion with the patient was warranted.

We did not substantiate that the patient’s complaints of infection were ignored. We could

neither confirm nor refute that nurses did not use aseptic technique when connecting

intravenous tubing due to the lack of specificity of the allegation.

We could neither confirm nor refute significant delays in access to primary care due to

the lack of specificity of the allegation. Performance measures for the primary care clinic

showed that the average wait time for appointments for established patients was less than

5 days.

We recommended that an external peer review be completed for appropriateness of care.

The Veterans Integrated Service Network and System Directors concurred with the

findings and recommendation and provided an acceptable action plan. 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, Veterans in Partnership (10N11)

SUBJECT:	 Healthcare Inspection – Quality of Care Issues, VA Northern Indiana

Health Care System, Fort Wayne, Indiana

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections (OHI)

received allegations regarding quality of care and delay in treatment of a patient at the

Fort Wayne Campus of the VA Northern Indiana Health Care System (the system), Fort

Wayne, IN. The purpose of the review was to determine whether the allegations had

merit.

Background

In 1995, the VA Northern Indiana Health Care System was formed by the integration of

VA Medical Centers in Fort Wayne and Marion, IN. The Fort Wayne campus provides

primary and secondary medical and surgical services, as well as mental health services.

Neurology Service, part of the Department of Medicine, was established in March 2009.

The service has one full-time neurologist and one part-time neurologist providing

neurology consultations, EEG interpretation, and compensation and pension

examinations. The system operates 26 hospital beds and is part of Veterans Integrated

Service Network (VISN) 11.

A complainant who received his health care from the system’s Ft. Wayne Campus, and

was followed at VA medical centers in Prescott, AZ and Tampa, FL contacted the OIG in

early June 2010, regarding the care he received from July 2009–April 2010. He sought

care for facial weakness and was initially diagnosed with Bell’s palsy (a neurological

disorder). He was subsequently diagnosed with myasthenia gravis (MG), a disease that

affects the connection between muscles and nerves. The complainant alleged that:

	 He received blood testing for his facial weakness in July 2009, but was not

informed of his abnormal laboratory test or correct diagnosis until

December 2009.

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Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

	 The delay in receiving the correct diagnosis and corresponding treatment may

have led to multiple emergency department (ED) visits and a hospital admission in

December 2009.

	 Staff did not believe him when he complained of an infection, resulting in a

hospital admission in April 2010.

	 Medication was prescribed that exacerbated his neurological condition.

	 Nurses did not use aseptic technique when reconnecting intravenous (IV) tubing.

	 The waiting time to see a primary care provider (PCP) was up to 4 weeks.

Bell’s Palsy

Bell’s palsy most commonly manifests as a sudden weakness of one side of the face. It is

the most common cause of sudden facial paralysis and caused by loss of function in the

nerve, which controls the muscles of the face (facial nerve). Even without treatment,

symptoms often resolve within weeks to months and there is a low likelihood of

recurrence. Treatment with prednisone or an antiviral medication may be prescribed to

speed recovery. Often a specific cause of Bell’s palsy cannot be found; however,

excluding more serious causes of facial paralysis should be considered if a patient does

not improve or has symptoms which differ from Bell’s palsy.

Myasthenia Gravis

MG is a disease that causes muscle fatigue and weakness. It often affects the muscles

that control speech, swallowing, and eye movements, as well as muscles of the arms and

legs. Antibodies against acetylcholine receptors (AChr) are produced when an

abnormally functioning immune system interrupts the signals between nerves and

muscles. The symptoms may vary significantly between individuals and from day to day.

A severe manifestation is myasthenic crisis, which occurs when a patient’s breathing

muscles have weakened to the point that they have difficulty breathing and may require

mechanical ventilation for adequate respiration.

MG may limit routine activities such as eating, walking, and personal hygiene.

Environmental factors can worsen these functional limitations or trigger episodes, and

individuals with MG are advised to avoid overexertion and temperature extremes.

Certain medications are also known to worsen MG and caution should be exercised with

new over-the-counter or prescription medications.

This disease is a relatively uncommon disorder with an annual incidence of five new

cases per million people in the United States. This rarity makes diagnosis of MG

challenging, as there are more common diseases that produce some of the same

symptoms. In addition to the clinical history and physical examination, various tests are

VA Office of Inspector General 2 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

used to confirm the diagnosis of MG, including blood tests (the AChR antibody), nerve

and muscle tests, and imaging tests.

Several options are available for the treatment of MG including: medications to facilitate

the signaling between muscles and nerves and suppress abnormal antibody production,

plasmapheresis (blood exchange) to remove the abnormal antibodies, and removal of the

thymus gland. The response to the treatment for MG can vary between individuals and

trying several options may be necessary to find an effective treatment.

Scope and Methodology

We reviewed the patient’s electronic medical record (EMR), local and Veterans Health

Administration (VHA) policies, and medical literature related to MG. We also reviewed

quality management documents and private hospital records. We conducted a site visit

on August 24–25, 2010. We interviewed quality management staff, primary care

providers, the VA neurologist, an ED physician, and the Medical Service Associate Chief

of Staff. We also discussed MG with experts in the field.

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 patient is a male in his 60s with a past medical history of chronic obstructive

pulmonary disease (COPD)1 and tobacco abuse. In early April 2009, he was seen by a

PCP with complaints of left facial paralysis, difficulty chewing food, and partial left eye

ptosis (eyelid closure) for 2 weeks. He was diagnosed with possible left-sided Bell’s

palsy, placed on a tapered dose of prednisone (a synthetic corticosteroid drug used to

suppress the immune system), and speech therapy was consulted.

Six days later, the speech pathologist documented a history of additional symptoms,

including oral muscle fatigue, dysphagia (difficulty swallowing), and speech

abnormalities when tired. Two weeks later, the patient had a follow-up visit and the PCP

noted some improvement. The patient was scheduled for a return examination in 6

months.

Two months later, he was seen in the ED with complaints of acute facial weakness and

difficulty speaking. He was again diagnosed with Bell’s palsy, placed on valacyclovir

(an antiviral medication), and given a short course of prednisone. The ED physician

requested a consult for Neurology Service to see the patient for Bell’s palsy.

1 Chronic obstructive pulmonary disease refers to a group of lung diseases that block airflow and breathing.

VA Office of Inspector General 3 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Two days later, a neurologist examined the patient and noted that the patient had daily

pain consistent with migraine headaches and a history of Bell’s palsy. The neurologist

found that the patient showed some improvement on medication, but did not have

complete recovery. The neurological exam showed “a decreased nasolabial fold on the

left side.”2 Laboratory tests ordered at this visit included a sedimentation rate, C-reactive

protein, acetylcholine receptor (AChR) antibody,3 and a Lyme disease titer. The patient

was asked to return to the clinic in 3–4 months. The neurologist also ordered an ear,

nose, and throat (ENT) consult which was scheduled for mid-August, however, the

patient cancelled the appointment.

In early September, the patient was seen in the ED at the VA Medical Center in Prescott,

AZ, with complaints of left facial weakness. The neurological exam was positive for a

left flat nasolabial fold and a slight left lip droop. He was diagnosed with recurrent Bell’s

palsy and prescribed acyclovir (antiviral medication) and prednisone; these medications

helped reduce symptoms in the past.

In mid-October, the patient presented to the ED at the James Haley VA Hospital in

Tampa, FL, with complaints of difficulty chewing food and a history of recurrent Bell’s

palsy. The neurological exam was positive for mild left eye ptosis and a slight left lip

droop. He was again prescribed acyclovir and prednisone, and instructed to follow up

with his PCP and neurologist in Indiana.

In mid-November, the patient had recurrent symptoms of dysphagia and ptosis, and was

seen by his PCP. The PCP requested a neurology consult for within 1 week. Because the

patient’s symptoms were not service connected, the consult was changed to the next

available appointment (which was in December), with the option to be seen at the

Indianapolis VA Medical Center, if needed.

In early December, a PCP saw the patient because he had no resolution of symptoms

since his previous visit to primary care. He continued to have problems with chewing,

swallowing, difficulty breathing when eating, and jaw pain. The patient was encouraged

to see the neurologist in 6 days, and an ENT consult was renewed.

Six days later, the patient saw the neurologist as scheduled. Since his last visit, he had

received five short courses of prednisone from different ED and PCP providers, with

improvement noted each time. The patient had recurrent symptoms of left-sided eye

ptosis, and difficulty chewing and swallowing. The patient also reported speech changes.

The neurologist informed the patient of the positive AChR antibody from July at this

time, and diagnosed the patient with “possible MG,”4 history of Bell’s palsy, and

2 A decreased nasolabial fold is a finding that may indicate decreased function of the facial nerve and muscles.

3 Patients who have detectable antibodies to the acetylcholine receptor are considered seropositive for MG. 4 MG is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal

muscles of the body.

VA Office of Inspector General 4 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

migraine headaches. The treatment plan included a trial of Mestinon® 30 mg,

4 times daily, and a return to the clinic in 2–3 months.

A week later, the patient called the neurologist and complained of difficulty breathing

and blurred vision. The patient had increased the Mestinon® to 60 mg, 4 times daily 4

days earlier. The neurologist advised him to reduce the dose to 30 mg, 4 times daily, or

taper off completely if the symptoms did not improve. He was instructed to come to the

ED if necessary.

The next day, the patient was seen in the ED with speech problems, inability to chew and

swallow solids, double vision, ptosis, and numbness and weakness in his right little

finger. The ED physician contacted the neurologist by phone, and the neurologist

ordered discontinuation of the Mestinon® and requested transfer of the patient to a local

hospital, because the system was unable to provide the required intensive care services.

The patient was transferred to the local, non-VA hospital and treated for MG with

myasthenic crisis and COPD without respiratory failure. He was discharged from the

local hospital 6 days later.

After his discharge, the patient chose to have his MG managed by a neurologist in the

private sector but continued to see his VA PCP for other care. In late January 2010, the

patient had a follow-up visit with his PCP for management of low back pain. According

to the EMR, the patient was to return to primary care in 4 months, or earlier if needed.

In early February, the patient called the telephone triage in primary care with complaints

of coughing and wheezing. The PCP advised the patient to come to the ED if symptoms

did not improve. The patient was seen in the ED 6 days later and was given azithromycin

(an antibiotic) for bronchitis. He was seen again in the ED 13 days later for pain and

cellulitis of the left arm and received sulfamethoxazole and trimethoprim (an antibiotic)

for the cellulitis. The patient returned to the ED for a follow-up visit 4 days later and

improvement was noted in the EMR.

The patient returned to the ED 6 days later with continued complaints of left hand

swelling and possible infection, and a provider prescribed clindamycin (an antibiotic).

The patient returned to the ED 5 days later. The ED physician discontinued the

clindamycin, which made the MG worse, and prescribed cefuroxime (an antibiotic),

which does not worsen MG symptoms, for the patient’s left hand infection. Four days

later, the patient presented to the ED provider with left arm paresthesia (numbness and

weakness) and resolving cellulitis. The patient was given baclofen (a muscle relaxant)

for the left arm paresthesia and was instructed to discontinue the medication if it made his

MG symptoms worse.

Four days later, the ED provider contacted the patient regarding an abnormal chest x-ray.

The x-ray showed an infiltrate (a sign of possible infection), and the provider ordered

azithromycin (an antibiotic) for a lung infection. The patient requested that the pharmacy

VA Office of Inspector General 5 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

review this medication to ensure that it would not exacerbate his MG. Two days later,

the pharmacy reported that there was a small chance the medication could cause a

reaction, so the provider changed the antibiotic to doxycyline.

During a scheduled appointment with the PCP in early April, the patient’s history of MG

with intermittent exacerbations, bronchitis, and left hand cellulitis was noted. The

treatment plan consisted of occupational therapy, continuation of fee-based neurology

services, and a return visit was scheduled for 1 month. Two weeks later, the patient was

admitted from the ED to the hospital for aggressive treatment of pneumonia and left hand

cellulitis. He was discharged 13 days later with plans to see the PCP in 9 days.

Inspection Results

Issue 1: Delay in Communicating Diagnosis

We substantiated the allegation that a neurologist evaluated the patient in July 2009, but

did not inform the patient of an abnormal laboratory test or his correct diagnosis until

early December.

The neurologist told us that he was aware of the AChR antibody results 48 hours after the

test was done in July, but he did not inform the patient of the results at that time because,

according to his exam, the patient was not symptomatic and he wished to explain the

diagnosis of MG to the patient in person. The neurologist also stated that he wanted to

see the patient acutely symptomatic to confirm the diagnosis, but he did not communicate

this to other providers. VHA policy5 requires patient notification of abnormal test results

within 14 days so that a treatment plan can be initiated or changed as soon as possible.

When the neurologist evaluated the patient in July 2009, the differential diagnoses listed

in the EMR included possible Giant Cell Arteritis (a condition that can cause headaches),

Lyme disease (a condition that can cause rash, fatigue, headache and weakness), and MG.

However, the neurologist told us he had not reviewed prior PCP notes or the speech

pathologist’s note in the EMR, which indicated a history of difficulty with chewing and

swallowing. Muscle weakness and fatigue is a cardinal sign of MG, and this important

information was not reviewed during the consultation. Incomplete review of the patient’s

history and physical and lack of timely follow-up of test results contributed to a delay in

communicating the diagnosis to other providers and the patient.

Issue 2: Delay in Treatment

We substantiated the allegation that a lack of prompt diagnosis and treatment may have

led to multiple ED visits and a hospital admission in mid-December 2009.

5 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.

VA Office of Inspector General 6 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

The patient was originally diagnosed and treated for Bell’s palsy in April 2009. The

patient was seen by the neurologist in July 2009, but was not diagnosed with MG until

December 2009. The neurologist did not inform the patient or other providers of test

results in a timely manner, and the patient, believing he had Bell’s palsy, cancelled an

ENT consult in August and a neurology appointment in October. The delay in diagnosis

and cancelled appointments by the patient resulted in missed opportunities to treat his

MG.

In September 2009, the patient experienced recurrent neurological symptoms and sought

care in the ED at the VA Medical Center in Prescott, AZ. In October 2009, he was seen

in the ED at the James Haley VA Hospital, in Tampa, FL, with an exacerbation of his

neurologic symptoms.

The patient returned to primary care in Fort Wayne, Indiana with ongoing, acute

neurological symptoms in mid-November and early December 2009. Bell’s palsy is

usually a self-limited process, and most patients achieve complete spontaneous recovery

within 2 weeks.6 Bell’s palsy rarely recurs, so the patient’s recurrent symptoms,

including facial palsy, should have alerted providers to a more serious neurological

condition. The patient saw the neurologist in early December 2009, and he was started

on a trial dose of Mestinon®.

The patient was seen in the ED 9 days later, in acute myasthenic crisis. He was

immediately transferred to a local hospital, because the system was unable to provide the

required intensive care services. We found that that patient was not aggressively treated

for MG until his emergency admission to the local hospital, and that early diagnosis and

more aggressive initial treatment of MG by the neurologist may have prevented multiple

ED visits and an emergency admission for myasthenic crisis.

Issue 3: Complaints of Infection Ignored

We did not substantiate the allegation that the staff ignored complaints of an infection

leading to a hospital admission in mid-April 2010.

The EMR noted that the PCP and ED providers had evaluated and treated the patient for

infection and cellulitis on multiple occasions prior to the admission. The patient had

two ED visits in February and March, and a follow-up appointment with the PCP in

early April 2010, for evaluation and treatment of his cellulitis.

Issue 4: Medication Exacerbated Condition

We substantiated the allegation that a provider in the ED prescribed medication that

exacerbated MG.

6 Gilden DH, Bell’s Palsy, New England Journal of Medicine, 351:1323-1331, September 23, 2004.

VA Office of Inspector General 7 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Clindamycin (an antibiotic used to treat infection) must be used with caution in patients

with the diagnosis of MG,7 as it can cause a significant increase in weakness.

Clindamycin was prescribed in early March 2010, in spite of the fact that the patient had

given the ED providers a list of medications, including clindamycin, that exacerbated

MG. The provider told us that she had a copy of the list when she prescribed the

medication but felt that the patient could have had an antibiotic resistant infection and

made a clinical judgment to use the medication.

We found no documentation in the EMR that risks, benefits, or alternatives for this

medication were considered by the provider or discussed with the patient. An ED

physician discontinued the medication 5 days later, when the patient presented with

symptoms consistent with an exacerbation of MG.

Issue 5: Breach in Aseptic Technique

We could neither confirm nor refute the allegation that nurses did not use aseptic

technique when connecting his IV tubing because of the lack of specificity of the

complaint.

The complainant stated that he observed IV tubing being re-used for intermittent IV

medications. It is not known if sterility of the tubing was maintained between uses. We

reviewed infection control data, and the facility did not have any documentation of

infections related to IV therapy. The system guidelines on IV therapy included steps in a

checklist to maintain aseptic technique when changing IV tubing. Nurses must complete

an IV class and demonstrate competency before they are permitted to administer any type

of IV therapy.

Issue 6: Delay in Primary Care Access

We could neither confirm nor refute the allegation that it took up to 4 weeks to see a PCP

due to the lack of specificity of the complaint.

We reviewed performance measures for the system’s primary care clinic and found that

in FY 2009 to March 2010 the average wait time for appointments for established

patients was less than 5 days. The allegation lacked specificity regarding when this

occurred, and the EMR did not reflect that the patient requested to be seen by primary

care and was not accommodated. When the patient called the primary care clinic or

telephone triage with concerns that required immediate attention, he was referred to

ambulatory care or the ED and was seen the same day.

7 Bird, SJ, Treatment of Myasthenia Gravis, UpToDate®, February 3, 2010.

VA Office of Inspector General 8 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Conclusions

We substantiated that there were delays in the notification of test results and the diagnosis

of MG and missed opportunities in treatment and follow-up of the patient. We found that

a neurologist was aware of abnormal test results suggestive of MG in July 2009, but he

did not inform the patient until December 2009.

We substantiated that a lack of prompt treatment and diagnosis may have led to multiple

ED visits and a subsequent hospital admission. The patient was seen by multiple ED and

primary care providers between April 2009 and December 2009; however, aggressive

treatment for his MG was delayed until December 2009 when he was hospitalized in

myasthenic crisis.

We substantiated that medication was prescribed that exacerbated the patient’s MG.

While there were clinical reasons for prescribing an antibiotic, given the known risk of

this specific medication, the potential severity of the side effects, and the patient’s recent

hospitalization for a myasthenic crisis, a more extensive search for a safer medication or

a more detailed discussion with the patient was warranted.

We did not substantiate the allegation that complaints of infection were ignored. We

were unable to confirm or refute that there were breaches in aseptic technique during

intravenous therapy or that there were delays in access to primary care.

Recommendation

Recommendation. We recommend that that an external peer review be completed for

appropriateness of care.

Comments

The VISN and System Directors agreed with the findings and recommendation and

provided an acceptable action plan (see Appendixes A and B, pages 10–12, for the

Directors’ comments). 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 9 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix A

VISN Director Comments

Department of

Veterans Affairs Memorandum

Date: February 8, 2011

From: Director, Veterans in Partnership (10N11)

Subject: Healthcare Inspection – Quality of Care Issues, VA Northern 

Indiana Health Care System, Fort Wayne, Indiana 

To: Associate Director, St. Petersburg Office of Healthcare Inspections

(54SP)

Thru: Director, Management Review Service (10B5)

Attached, please find the response from NIHCS. If you have

any questions, please contact Jim Rice, Quality Management

Officer, at (734)-222-4314.

Michael S. Finegan

Network Director, VISN 11

10 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix B

System Director Comments

Department of

Veterans Affairs Memorandum

Date:	 February 1, 2011

From:	 Director, VA Northern Indiana Health Care System (610/A4)

Subject:	 Healthcare Inspection – Quality of Care Issues, VA Northern 

Indiana Health Care System, Fort Wayne, Indiana 

To:	 Director, Veterans in Partnership (10N11)

1. The Leadership has reviewed the draft inspection report of

the Review of Quality of Care conducted by the Office of

Healthcare Inspections. Our response to the recommendation

is attached.

2. We appreciate the completeness of the review that was

conducted for this very complex case involving a veteran with

unique medical issues. We concur with the recommendations

and our action plan will increase provider education in an

effort to mitigate future high-risk situations of this nature.

(original signed by:) 

Daniel Hendee, FACHE
 

Director, VA Northern Indiana Healthcare System (610/A4)
 

VA Office of Inspector General 11 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

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 recommend that an external peer review be

completed for appropriateness of care.

Concur Target Completion Date: March 18, 2011

Facility’s Response: In response to the OIG Draft Report – Quality of Care

Issues – VA Northern Indiana Health Care System, Fort Wayne, Indiana,

VA Northern Indiana Health Care System submits that this case was sent

for External Peer Review on February 1, 2011.

Additional training on the proper treatment for Myasthenia Gravis will be

provided in an upcoming Medical Staff Meeting.

Status: In process

12 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix C

OIG Contact and Staff Acknowledgments

OIG Contact Carol Torczon, Associate Director

St. Petersburg Office of Healthcare Inspections

Acknowledgments	 David Griffith, Team Leader

Christa Sisterhen

George Wesley, MD

Robert Yang, MD

VA Office of Inspector General 13 
Quality of Care Issues, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix D

Report Distribution
 

VA DistributionVA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, Veterans in Partnership (10N11)

Director, VA Northern Indiana Health Care System-Fort Wayne Campus (610/A4)

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: Daniel Coats, Richard G. Lugar

U.S. House of Representatives: Dan Burton, Mike Pence, Marlin Stutzman

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

VA Office of Inspector General 14