OIG conducted an inspection in response to complaints about the timeliness and quality of care in the Emergency Department (ED) and Primary Care of the Memphis VA Medical Center (facility), Memphis, TN, which is part of Veterans Integrated Service Network (VISN) 9.

OIG did not substantiate the allegation that Memphis ED personnel were inattentive and failed to provide timely care.

The patient was triaged appropriately on arrival. The 4-hour delay the patient experienced before leaving without being seen by an ED provider was unfortunate yet unavoidable due to the patient population in the ED at the time of the patient’s visit. OIG did not substantiate the allegation that Primary Care provider assistants were inattentive to the patient’s requests for medical help via phone and VA’s electronic secure messaging system. Primary Care clinic staff responded to the patient’s requests, and the patient received the services he requested. While OIG found occasional delays in responding to the patient’s requests, overall, delays were not typical. OIG substantiated the allegation that VA refused to pay for private facility care; however, this decision was based on Federal regulations. OIG substantiated the allegation that the facility faxed incorrect records to the ED of a private hospital. This was attributed to human error by a staff member at the facility, and as a result, the facility changed its process for providing medical information to other hospitals. OIG found that the new process was being followed at the time of our visit; therefore, OIG made no recommendation. OIG did not substantiate the allegation that the facility ignored recommendations or postponed implementation of actions recommended by the OIG in previous reports. OIG made no recommendations.