An inspection at the Leavenworth VA Medical Center found that a patient with a possible malignancy result was notified by a physician 288 days after the test was completed.
Ten months after the initial CT scan, the patient was diagnosed with stage three lung cancer with the possibility of metastatic disease. The patient died in the summer of 2017, according to the Office of the Inspector General's report.
The inspection was initiated after an individual made an allegation in November 2017 about delays in a lung cancer diagnosis and the reporting of an abnormal radiology test. The complainant also said a provider falsely documented the patient initially wasn't willing to have the test conducted. The OIG substantiated the claims, finding that the patient never refused the test or intervention.
Three subsequent allegations were unsubstantiated.
The OIG conducted a site visit from June 4 to 7, 2018.
The agency determined the patient's records weren't assigned the appropriate code for follow-up. Officials examined cases with the follow-up notification and found that 45 out of 249 veterans — or 18 percent — didn't receive communication of the results within the required timeframe or that the results weren't documented in their electronic health records. The OIG concluded there was evidence of ongoing care and the patients didn't suffer adverse outcomes because of the delays.
According to the VA's policy, test results requiring action must be communicated in seven calendar days. Normal results must be communicated within 14 days.
The inspection also found radiologists didn't receive training on new diagnostic codes or software that generates notifications.
Five recommendations were issued on training, timely communication and adherence to other VA policies.
"We appreciate the inspector general’s oversight, which in this case focuses on events that occurred in 2017," said Joe Burks, spokesman for VA Eastern Kansas Health Care System. "Since then, the Leavenworth VA Medical Center has taken steps to address and implement each of the IG’s recommendations."
Burks said the Leavenworth hospital has undergone changes to simplify diagnostic coding, train employees and update their policies to prevent similar issues in the future.
According to the report, a team from the VA Eastern Kansas Health Care System met with the veteran's spouse and adult child and a full disclosure was given, as was an apology. The family also was notified of their right to seek legal advice under the Federal Tort Claims Act.