The VA Office of Inspector General (OIG) has found that a patient's care was compromised due to delayed diagnosis and treatment of lung cancer at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth.
Neither the patient aligned care team provider (PACT) nor the system pulmonologist "took the necessary steps to ensure a bronchoscopy was ordered and completed," the OIG reported, noting that the PACT provider "ordered, but failed to track, a [PET] scan completed by a community provider … and failed to communicate the abnormal results to the patient and initiate clinical actions as indicated." Furthermore, although the healthcare system conducted an "institutional disclosure" to the patient, this documentation didn't include key details.
The OIG also reported the following:
- Community care staff did not make "timely, sufficient efforts to retrieve the patient's PET scan results."
- There was a "broad system failure of community care staff not making three attempts to retrieve patient records within 90 days of completed appointments."
- The LCS program lacked "oversight, multidisciplinary engagement, policy, and adequate primary care training and engagement."
As the result of this investigation, the OIG made one recommendation to the state's secretary for health related to the communication of patients' abnormal test results and one recommendation to the Veterans Integrated Service Network director regarding the system's LCS program, it said.
