Inspector General report critical of former Montana VA chief of staff, facility oversight
The Department of Veterans Affairs’ Office of Inspector General released a report this week that found the former Montana VA Health Care System chief of staff at Fort Harrison performed pregnancy care for a patient when he was not allowed to and also identified other oversight issues with leadership at the facility.
The care the former chief of staff, Dr. J.P. Maganito, provided the woman during both her second and third trimesters, when he was not allowed to do so, put the woman and her fetus at risk of complications and even death, the report said.
And the oversight failures among leadership at the facility led to overlooked quality of care concerns, failure to complete professional practice evaluations for the chief of staff, and the failure to report him to the state licensing board on multiple occasions.
Duane Gill, the interim executive director of the Montana VA Health Care System, said in a statement the organization “deeply regrets” the circumstances that led to the 2022 investigation.
The OIG investigation started in June 2022, and investigators visited Fort Harrison in late August for a site visit, after receiving four complaints in the first half of that year. Those complaints said Maganito provided pregnancy care outside his approved privileges, that he provided substandard pregnancy care to another patient, that his care during a gynecologic surgery resulted in a negative clinical outcome, and that privileging processes that determine what care a doctor or nurse can provide were not being followed, according to the report.
“Privileging” is how health care facilities give permission to a provider to perform certain services based on their license and the resources at the facility, according to the OIG report.
It found that Maganito and the facility did not allow providers at Fort Harrison to perform pregnancy care after the first trimester of a pregnancy because the facility did not have the necessary infrastructure.
Maganito initially referred a woman the report refers to as “Patient 1” to a community-based OB/GYN after she became pregnant, but that provider left town during her second trimester, and she asked him to help with her care until she could reconnect with the OB/GYN.
It says the woman saw Maganito seven times during her second and third trimester, including twice for severe pregnancy complications late in her pregnancy.
But the report says he should have referred her to outside care. Instead, the care he did provide her during the complications was substandard and put her and the fetus at risk, the report says.
“Delaying the evaluation for HELLP syndrome and performing the evaluation for preterm PROM at the facility, which was not capable of providing pregnancy care, put Patient 1 and her fetus at risk for complications of pregnancy, including preterm delivery and death.”
HELPP, or hemolysis, is a serious, sometimes life-threatening condition that involves liver enzymes, blood platelets, and high blood pressure. PROM means “premature rupture of the membranes” during pregnancy.
The report found the facility also did not have properly trained staff or equipment to manage those complications, in addition to the other violations.
It also identified instances in which Maganito did not follow clinical standards when he failed to perform a biopsy to rule out cancer before performing an endometrial ablation on a different patient, and later ordered the wrong antibiotics for the woman to treat a separate issue, though the OIG said it was unable to determine if a different strategy on the antibiotic choice would have resulted in a different outcome.
But his failure to perform biopsies in 32 of 35 endometrial ablations during three years “placed patients at risk of a failure to detect endometrial cancer, which is a contraindication for endometrial ablation and should be ruled out prior to endometrial ablation procedures,” the report says.
It also found failures in leadership oversight that led to “risks to patient safety,” including not completing professional practice evaluations every six months, which in turn led to missed problems in quality of care at the facility.
A lack of communication between the chief of staff and chief of surgery also could have contributed to a lack of understanding of Maganito’s privileges, the report found, but it also found that privileges were approved in 2021 that had not been presented to a committee that hands out credentials.
The report also found the facility director on multiple occasions failed to report to the state licensing board some of the concerns reported to them about the care Maganito was providing within 100 days as required by VA policy.
The report says Maganito resigned three days after the OIG completed its on-site visit and that he would not speak with investigators. The OIG issued a subpoena to compel his testimony, but his attorney declined to comply, forcing the OIG to get a federal court order compelling Maganito to comply with the investigation. The OIG did not interview him until this past June, according to the report.
The report makes 10 recommendations surrounding maternity care, semi-annual evaluations and reviews of practice and reporting, and to ensure the facility is adhering to its privileges and standards of care, among other things.
The Montana VA said it is working on action plans to address the six recommendations specified for the facility, and other parts of the VA network are doing the same on their recommendations.
The Montana VA said it “initiated aggressive actions” to address the allegations against Maganito and had notified all state licensing boards in the states he is licensed in about the allegations and investigation.
“We take such incidents with the utmost seriousness, as the well-being of our patients is our top priority,” Gill said.
Maganito could not be reached for comment Thursday. In a check on Wednesday, the Montana Board of Medical Examiners shows Maganito’s license as active and his address in Bozeman. He has no disciplinary actions taken against his license. He was first licensed in Montana in 2015. His current license expires in 2025.va oig-22-02975-70