FAYETTEVILLE, Ark. (KNWA/KFTA) — On September 12, the Department of Veterans Affairs (VA) Office of Inspector General (OIG) released a report on community care coordination delays involving a patient with oral cancer at the Veterans Health Care System of the Ozarks in Fayetteville.

That patient died, and a healthcare inspection was made to assess whether care coordination delays may have contributed to his death. The report states that the OIG “evaluated the facility’s coordination of radiation therapy and chemotherapy for the patient.” It also evaluated a “related concern” regarding scheduling appointments for the patient’s radical resection surgery.

It noted that the patient was in his 70s, and had “a history of head and neck cancers, including laryngeal cancer and oral verrucous carcinoma.” An initial consult for his surgery was set for March 8, 2020 but he did not undergo the necessary surgery until September 29, 2020.

The OIG determined that facility OCC staff failed to schedule community care appointments for the patient within 30 days of the clinically indicated date determined by the provider, per Veterans Health Administration (VHA) policy. The OIG found that facility OCC staff did not thoroughly review the patient’s EHR when coordinating community care services for the patient, which ultimately delayed access to care and the patient’s surgery. Facility OCC staff did not take action for over three months on the first consult for community care, entered March 8, 2020. The OCC staff told the OIG the delays were due to not having ‘the time to put in enough effort’ to follow up on scheduling an appointment, and ‘missing information’ needed to schedule the patient with a community provider.

President and Founder of Bo’s Blessings Jannie Layne said the report is heartbreaking to read.

“Grief, I cried,” Layne said. “I still cry thinking about it, it was overwhelming sadness.”

Layne said a lot of things went wrong in getting care to the patient.

“The VA was responsible and community care was responsible,” Layne said. “The patient was responsible and that’s hard to say because he went to get help, he thought he was getting help and he didn’t get his help in a timely manner.”

Veterans Affairs Office of Inspector General report, September 12

The report also details delayed coordination of chemotherapy appointments for the patient. Three state lawmakers released statements about the report’s findings:

The report details an unacceptable failure on behalf of one of our heroes. Actions, or lack thereof, which jeopardize the health and well-being of any veteran breach the required and deserved standard of care. It’s a situation never to be repeated—and those liable must be held accountable. I will be working alongside my colleagues to ensure those obligations are met

Congressman Steve Womack

The report states that the seven-month surgical delay “placed the patient at a greater risk for disease progression.”

In this instance, the Fayetteville VA Medical Center failed to live up to its mission. Negligence in ensuring a veteran receives the quality and timely care they deserve is unacceptable. I will be working with my colleagues to ensure those responsible will be held accountable and this never happens again, in Arkansas or elsewhere

Senator John Boozman, a member of the Senate Veterans’ Affairs Committee

The facility ENT provider acknowledged “unnecessary delays” in scheduling the patient’s surgery, but noted it was impossible to know the exact effect of the delay.

The Fayetteville VA Medical Center’s staff failed in their duty to this veteran—completely unacceptable. I will work with my colleagues to investigate this incident, hold to account those responsible, and prevent this negligence in the future

Senator Tom Cotton

In addition to the report, the OIG has provided “an acceptable action plan” and stated that it “will follow up on the planned actions until they are completed.”

The Veterans Health Care System of the Ozarks (VHSO) responded to the report with the following statement.

The Veterans Health Care System of the Ozarks (VHSO) is committed to delivering the highest quality care to our Veterans. When a Veteran is sent to the community for specialized care, our staff in Office of Community Care (OCC) takes pride in finding those providers who can perform the procedures within a reasonable amount of time and recognize the complexity of the procedure. We deeply regret the delay in scheduling that occurred with one of our Veterans. As a result, the medical center will readdress all unscheduled community consults every 14 days regardless of community providers declining or if they are unable to perform the procedures. VHSO has addressed all three recommendations made in the OIG report.

Chris Myhaver, Interim Medical Center Director, Veterans Healthcare System of the Ozarks

Layne said she’s glad to see some progress from the report, but she said there’s still plenty of action to be taken to protect lives.

“I really want to look at this as an opportunity not to lay blame, but to find resolution and improve the situation,” Layne said.