Department of Veterans Affairs

In response to a request from Representative Tim Walz, the VA Office of Inspector General (OIG) reviewed the care of a patient who died from a self-inflicted gunshot wound less than 24 hours after discharge from the inpatient mental health unit of the Minneapolis VA Health Care System. The OIG...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Northport VA Medical Center (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV)...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Veterans Health Care System of the Ozarks (Facility). The review covered key clinical and administrative processes associated with promoting...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding inadequate nurse staffing that affected quality of care in the Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that nursing leaders were aware...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding quality of care issues in two Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated Patient A died at the facility after choking on food, but found...

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of several members of Congress to assess pain management practices including opioid prescribing and the treatment of substance abuse at Veterans Health Administration (VHA) medical facilities. The OIG found...

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Roseburg VA Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value...

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review a complaint alleging a delay in care, including surgery, after a non-VA imaging center reported mammogram results as normal for a patient with known breast cancer at the Atlanta VA Health Care System in Decatur...

The VA Office of Inspector General (OIG) reviewed the Wilmington Health Care Center (HCC) in North Carolina in response to a request from Congressman Walter B. Jones, who asked the OIG to determine whether selecting the Wilmington airport site for the HCC was in the best interest of taxpayers. He...