The Department of Veteran Affairs’ Office of Inspector General on Tuesday released a report stating the former chief of staff at the Montana VA Health Care System in Helena practiced without privileges when providing pregnancy care for a patient during her second and third trimesters.
The 70-page report, “Chief of Staff’s Provision of Care Without Privileges, Quality of Care Deficiencies, and Leaders’ Failures at the Montana VA Health Care System in Helena,” also found deficiencies in leaders’ oversight, resulting in failure to detect quality of care concerns and take action on those concerns, which presented risks to patient safety.
Montana VA at Fort Harrison put out a news release Tuesday shortly after the report was posted, saying from Jan. 7, 2022, through June 22, 2022, the Office of Inspector General received four complaints regarding then-Chief of Staff Dr. J.P. Maganito, which included the allegations:
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- The COS provided pregnancy care outside of approved privileges.
- The COS provided substandard advanced pregnancy care to a female patient.
- The COS provided substandard care during gynecologic surgery and post-operative care for another female patient, resulting in a negative clinical outcome.
- Appropriate credentialing and privileging processes were not followed for the COS.
- The COS providing pregnancy care outside the scope of the COS’s privileges.
“Specifically, ongoing professional practice evaluations (OPPEs) were not completed; privileging processes were not followed; and, when deficiencies in the COS’s care were identified, the concerns were not reported to the SLB as required,” it stated.
Attempts to reach Maganito on Tuesday were unsuccessful.
Montana VA said that prior to the release of Tuesday’s report, it had initiated “aggressive actions” to address the allegations against the former chief of staff. They also said they have been closely monitoring the investigation’s progress.
“Montana VA deeply regrets the circumstances that led to the investigation by the Office of Inspector General (OIG),” the Montana VA said in an email.
“We take such incidents with utmost seriousness, as the well-being of our patients is our top priority,” said Duane Gill, Montana VA Health Care System’s interim executive director.
They said the Office of Inspector General began an inspection in June 2022 and visited the site in August of that year.
Montana VA said the report found that Maganito violated VHA policy by acting outside of approved privileges and gave deficient quality of care to a pregnant patient as well as deficiencies in the quality of gynecologic surgery and post-operative care he provided for another patient.
The report also found that facility leaders failed to follow the privileging processes and VHA policy on state licensing board…
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