Report No. 06-03742-142 June 6, 2007

 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Quality of Care Issues 

VA Medical Center 

Atlanta, Georgia 

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

VA Office of Inspector General i 

Executive Summary 

The purpose of the review was to investigate allegations made by a complainant 

regarding patient care, communications, and cleanliness at the medical center. The 

complainant alleged that: (1) the patient did not receive timely diagnostic tests; (2) 

nothing was done to improve or stabilize the patient’s condition; (3) the patient went 

without food and water for extended periods; (4) providers did not discuss results of tests 

or the patient’s condition with the patient or his family; (5) sanitary conditions in the 

medical center were “horrific”; and (6) staff were impolite and uncooperative in 

responding to the complainant’s issues. The complainant further alleged that after 

presenting these concerns to the acting medical center director, the patient was 

discharged abruptly, in an unstable condition, without discharge instructions. 

We found that the patient received timely diagnostic tests and determined that appropriate 

care and treatment was provided to improve and stabilize the patient’s condition during 

hospitalization. While we determined that the patient did not receive anything to eat or 

drink for long periods, we did not substantiate the implied inappropriateness because the 

patient had been intermittently placed on NPO (Nothing per Oral/Nothing per Mouth) 

status to undergo testing. We could not confirm or refute poor communication between 

providers and the patient, or providers and members of the patient’s family. 

Additionally, we could not determine the degree of medical center cleanliness at the time 

of the patient’s hospitalization. We did not substantiate that medical center staff 

members were impolite and uncooperative during attempts to discuss the family’s 

concerns or that the patient was discharged abruptly because of family complaints to 

managers regarding the patient’s care. 

When we subsequently contacted the patient at his home, he indicated satisfaction with 

the care received and in retrospect, he and his family would not make the same 

complaints. Based on these findings, we did not make any recommendations. The acting 

medical center director concurred with our report findings. 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, VA Medical Center, Atlanta, Georgia (508/00) 

SUBJECT: Healthcare Inspection – Alleged Quality of Care Issues, VA Medical 

Center, Atlanta, Georgia 

Purpose 

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections conducted an evaluation to determine the validity of allegations of 

poor patient care at the Atlanta VA Medical Center (the medical center). 

Background 

The medical center is a tertiary care hospital that is part of Veterans Integrated Service 

Network (VISN) 7. The medical center provides primary and specialized outpatient 

health care, extended care, and acute inpatient medical, surgical, intermediate, and 

psychiatric care services. 

The complainant alleged that her father-in-law received poor care during his 5-day 

hospitalization. She alleged that: 

• The patient did not receive timely diagnostic tests. 

• The patient went without food and water for extended periods. 

• Providers did not discuss results of tests or the patient’s condition with the patient 

or his family. 

• Staff were impolite and uncooperative in responding to the complainant’s issues. 

• Nothing was done to improve or stabilize the patient’s condition. 

• Sanitary conditions in the medical center were “horrific.” 

The complainant further alleged that after presenting these concerns to the acting 

medical center director, the patient was discharged abruptly, in an unstable condition, 

without discharge instructions. 

VA Office of Inspector General 1 
Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

Scope and Methodology 

We reviewed the patient’s medical record, medical center and national policies, patient 

safety and environmental management records, and other applicable documents. We 

reviewed information from the patient advocate database. We contacted responsible 

medical center staff to determine if they were aware of the complaint and to identify 

actions taken as a result, and we spoke with the acting medical center director about his 

verbal exchange with the complainant. We reviewed documentation provided by the 

medical center to the VISN and the Veterans Health Administration (VHA) related to 

these complaints. We contacted the patient to discuss the specific issues outlined in the 

complaint and to inquire about his current health status. 

This review was performed in accordance with the Quality Standards for Inspections

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

Case Summary 

The 58-year-old patient was evaluated by a private sector physician on September 9, 

2006, for a 3-week history of neurological symptoms. The physician diagnosed Bell’s 

palsy and, since the patient did not have healthcare insurance, suggested obtaining 

additional medical care at the medical center. The patient, who had not received previous 

care at any VA facility, presented to the medical center emergency room 2 days later and 

was admitted for evaluation and testing. At the time of admission on September 11, the 

patient was alert and oriented to person, place, and time. The patient underwent a series 

of diagnostic laboratory and radiology tests over the course of his hospitalization and was 

subsequently diagnosed with a subacute ischemic cardiovascular accident (stroke). The 

patient was discharged in stable condition on September 15 with plans for continued 

neurology follow-up and monitoring by primary care. 

Inspection Results 

At the time of our contact with the patient, he requested that we not pursue this complaint 

any further and that we not contact the complainant, his daughter-in-law. The patient 

speculated that the concerns voiced by the complainant were possibly due to the 

emotional impact of the medical events and that, retrospectively, he would not share the 

same complaints at this time. We determined that the patient received appropriate care. 

Diagnostic Tests. We did not substantiate the allegation that the patient did not receive 

timely diagnostic tests. On September 11, the provider ordered computed tomography 

(CT) exams, an ultrasound Doppler examination of the carotid arteries, and a chest x-ray. 

On September 12, the provider ordered a magnetic resonance imaging (MRI) exam of the 

head and a magnetic resonance angiography (MRA) exam to evaluate cerebral 

circulation. All of these tests were completed within 2 days of the request. A 

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Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

transesophogeal echocardiogram (TEE)1 was ordered by the provider on September 11 

and the patient was placed in an overbook status (if cancellation occurs) on September 

14; the test was completed on September 15. In addition, the provider ordered several 

diagnostic laboratory tests, including a complete blood count (CBC), partial 

thromboplastin time (PTT),2

 urinalysis, and other routine tests to evaluate the patient’s 

health status. We found completion of all requested diagnostic tests within reasonable 

timeframes. 

Nutrition. We did substantiate that the patient did not receive anything to eat or drink for 

long periods during his hospitalization. However, this was appropriate because the 

patient had been intermittently placed on NPO (Nothing per Oral/Nothing per Mouth) 

status to undergo testing. The complainant alleged that the patient did not receive food or 

water for a 10-hour period on September 14 and, on September 15, had not received food 

or water since the family’s visit the previous day. We found documentation that, on 

September 14, the patient was NPO starting at 8:41 a.m. so he could be in an overbook 

status for a TEE later that day; the NPO continued through the lunchtime meal on 

September 14. The NPO status was continued until it was determined that the test could 

not be completed and staff ordered a late tray at 4:46 p.m. Medical record documentation 

indicates that the patient ate 75 percent of his dinnertime meal. 

The patient was again on NPO status beginning at 12:00 a.m. on September 15 with the 

TEE performed at 1:25 p.m. The patient returned to his hospital room at 3:15 p.m. and 

the NPO status continued until 3:30 p.m. to allow for interpretation of the results and to 

assure no further testing was required. The patient inquired about his discharge plans 

upon return to his hospital room after completion of the TEE, and the nursing staff 

notified the provider of the patient’s desire to go home. We did not find documentation 

that the patient requested a meal or that a late tray was ordered for this date. The 

discharge order was written at 5:25 p.m., and the patient was discharged at 6:45 p.m. 

Communication. We could not confirm or refute the allegation of poor communication 

between providers and the patient, or providers and members of the patient’s family. We 

did not find clear documentation of discussions with the patient or family except for the 

discharge instructions. However, during our interview, the patient did not voice concerns 

regarding poor communication by his medical providers at the time of his hospitalization. 

We did not substantiate the allegation that medical center staff, including the “hospital 

administrator,” were impolite and uncooperative during attempts to discuss the family’s 

concerns at the time of the patient’s hospitalization. In response to the letter of complaint 

to the OIG, a copy of which the complainant had also sent to the medical center, the 

acting director contacted the complainant by phone on September 29 to determine the 

patient’s current condition. Immediately after he introduced himself, the complainant 

 

1

 The test is used to detect clots inside the left atrium of the heart for patients who have had a stroke. 

2

 A test that measures clotting time in plasma (the liquid portion of blood). 

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Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

realized that the acting director, who speaks with a distinct accent, was not the person she 

had voiced concerns to. The remainder of the phone conversations focused on the 

patient’s health status. We also found that the patient advocate did not have any record 

that the complainant or patient voiced any concerns about staff courtesy. 

Condition Improvement/Stabilization. We did not substantiate the allegation that nothing 

was done to improve or stabilize the patient’s condition. Please see the above section 

regarding diagnostic testing for his stroke. The medical record documents that the patient 

was not experiencing an acute or imminent stroke on presentation to the medical center, 

but was found to have suffered a recent (subacute) stroke. We found that the patient was 

started on therapeutic dosages of aspirin (helps prevent the recurrence of a stroke) and a 

statin drug (used to reduce cholesterol). Additionally, the discharge summary documents 

almost complete resolution of stroke symptoms at the time of discharge. 

Cleanliness. We could not determine the medical center’s degree of cleanliness at the 

time of the patient’s hospitalization in September 2006. However, for the period May 

through October 2006, we did not identify any complaints to the patient advocate related 

to cleanliness or safety on the patient’s hospital unit. Additionally, the medical center has 

been recognized for ongoing efforts in cleanliness, including performance at or above the 

standard during 2005 and 2006 Annual Workplace Evaluations and during the 2006 OIG 

Combined Assessment Program Review of the Atlanta VA Medical Center, Report No. 

06-01571-231, issued September 29, 2006. 

Discharge Planning. We did not substantiate the allegation that the patient was 

discharged abruptly because a family member complained to managers about his care. 

The patient was undergoing diagnostic testing for his stroke throughout his 

hospitalization. A September 15 progress note, timed at 11:57 a.m., states “TEE: today, 

according to results may discharge pt [patient] today with f/u [follow up] with neurology 

as outpt [outpatient].” The discharge occurred at 5:25 p.m., a few hours after completion 

of the final diagnostic test (the TEE) on September 15. The discharge instructions 

provided clear information on the patient’s diagnosis, medication regimen, and the plan 

for continued outpatient follow-up with neurology providers. 

In our conversation with the patient, he reported feeling well and stated that he was 

returning to work on a part-time basis. Medical record documentation reflects 

appropriate arrangement of outpatient follow-up care with a VA primary care provider 

and neurologist. 

Conclusion 

We found that the patient received appropriate and timely medical care. We did not 

substantiate the quality of care allegations. We could not confirm or refute the allegation 

regarding poor communication and unit cleanliness at the time of hospitalization. The 

patient indicated that he was satisfied with the care he had received, and in retrospect, he 

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Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

told us he thought the complainant’s concerns may have been due to the emotional 

impact of medical events at the time of hospitalization. Based on these findings, we did 

not make any recommendations. The medical center director concurred with our 

findings. We consider the issue closed. 

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

Assistant Inspector General for 

Healthcare Inspections 

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Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia 

Appendix A 

OIG Contact and Staff Acknowledgments 

OIG Contact Victoria H. Coates 

Director, Atlanta Office of Healthcare Inspections 

(404) 929-5962 

Acknowledgments Toni Woodard, Healthcare Inspector 

Michael Shepherd, M.D. 

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Alleged Quality of Care Issues, VA Medical Center, Atlanta, Georgia

Appendix B 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southeast Healthcare Network (10N7) 

Director, Atlanta VA Medical Center (508/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Saxby Chambliss, Johnny Isakson 

U.S. House of Representatives: John Lewis, David Scott 

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

VA Office of Inspector General 7