FAYETTEVILLE -- A patient with oral cancer died after a series of delays in care by staff at the Veterans Health Care System of the Ozarks, according to a new report.
The report, released Monday, outlines the results of an inspection by the U.S. Department of Veterans Affairs Office of Inspector General into an allegation of community care coordination delays at the Fayetteville medical center.
Delays in scheduling and coordination "limited the patient's opportunity to receive optimal treatment and potentially a more favorable outcome," according to the report's executive summary.
The Office of Inspector General was unable to determine whether the delays contributed to the patient's death, due to the aggressive nature of the cancer and complexity of treatments.
The office found radical resection surgery was recommended by a facility ear, nose and throat provider and agreed to by the patient on March 8, 2020, but Office of Community Care staff did not take action for over three months after the first consult.
The facility ear, nose, and throat provider referred the patient to a community hospital, because the VA center does not offer the surgery, according to the report.
Staff did not schedule an evaluation appointment with a community head and neck surgeon until after a delay of 140 days, the report states. Veterans Health Administration policy is to schedule community care appointments within 30 days.
"Due to a series of delays and lack of follow-up by the facility's Office of Community Care staff, the patient was not evaluated by a head and neck surgeon at a community hospital for six months and did not undergo the necessary surgery at a community hospital until Sept. 29, 2020," the report states. "The patient waited 205 days between the initial consult and the surgery."
Care and surgery for the patient were delayed because Office of Community Care staff did not thoroughly review the patient's electronic health record when coordinating community care services for the patient, according to the report.
Community Care staff also "failed to coordinate the patient's post-surgical radiation therapy" and "delayed coordinating chemotherapy within the community provider's requested six-week timeline," the report states.
Over nine weeks passed between the surgery and a follow-up oncology appointment at the facility, according to the report. The patient, who had a history of head and neck cancers, saw a facility oncology resident on Dec. 4, 2020. The resident noted the patient was "already almost three months out" from surgery and the benefits of radiation therapy for the patient were "diminished at this point."
The patient was placed on palliative care in early 2021 and died during the next month, according to the report.
The report says the Fayetteville facility's director needs to monitor and ensure Community Care staff take action on active consults within seven days, schedule community care appointments within 30 days and evaluate and correct flaws in the process of authorizing requests for community care.
The medical center has addressed the three recommendations made by the Inspector General's Office in the report and will readdress all unscheduled community consults every 14 days, according to a statement attributed to interim medical center Director Christopher Myhaver and emailed to the Northwest Arkansas Democrat-Gazette.
"The Veterans Health Care System of the Ozarks is committed to delivering the highest quality care," according to the statement. "We deeply regret the delay in scheduling that occurred with one of our veterans."
U.S. Sen. John Boozman, R-Ark. and a member of the Senate Committee on Veterans' Affairs, said in a news release the delays were a failure by the Fayetteville facility "to live up to its mission." In the same release, U.S. Sen. Tom Cotton and U.S. Rep. Steve Womack, both R-Ark., both called the delays "unacceptable."