VAOIG Inspection of Salt Lake City VA

Healthcare Inspection Alleged Quality of Care Issues VA Salt Lake City Health Care System Salt Lake City, Utah 01/01/10. The purpose of the review was to determine the validity of the following allegations: (1) lack of collaboration, inappropriate care, and deaths; (2) unwarranted amputations; and (3) inappropriate management of vein patients. We substantiated poor collaboration between Interventional Radiology and Vascular Surgery for two of the four patients but concluded that this did not directly contribute to the fatal outcomes. We concluded that the system took appropriate actions to review the quality of care and make system improvements, which included conducting institutional disclosures in two of the four cases. However, we determined that the system needed to refer a case to Regional Counsel for guidance. We did not substantiate the occurrence of unwarranted amputations or inappropriate management of vein patients. We recommended that the system refer Patient Case 2 to Regional Counsel to determine whether the system has an obligation to report the providers to the National Practitioner Data Base. Since management had already addressed the issue, we consider this recommendation closed. VAOIG