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Healthcare Inspection Quality of Care, South Texas Veterans Health Care System, San Antonio, Texas
Report Number 08-01825-20, 11/6/2008 | Full Report (PDF)
The purpose of the review was to evaluate allegations of cancellation of procedures, poor care, and neglect of a patient at the South Texas Veterans Health Care System. We did not substantiate allegations of poor care and neglect related to open heart surgery. The patient’s care was highly complex, beginning with the inability to complete a three-vessel bypass intra-operatively due to the patient’s particular coronary artery anatomy, post-operative complications, and wound separation. We substantiated that two cancellations of procedures occurred but found that at least one of these cancellations was associated with the needs of an emergent case. Although there was an unacceptable delay in responding to a call light, we did not substantiate that it nearly caused the patient’s death. Finally, while we found that the patient suffered pain consistent with his overall condition, we did not substantiate that he was neglected. We recommended that management implement processes for timely response to patient call lights.