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Source Id
324

Comprehensive Healthcare Inspection of the VA Bedford Healthcare System in Massachusetts

2024
23-00101-137
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Bedford Healthcare System, which includes the Edith Nourse Rogers Memorial...

Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida

2024
22-04014-130
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Bay Pines VA Healthcare System, which includes the C.W. Bill Young VA Medical...

Veterans Health Administration’s Failure to Properly Identify and Exclude Ineligible Providers from the VA Community Care Program

2024
22-02398-131
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a focused national review to assess concerns with Veterans Health Administration’s (VHA’s) process to identify providers who have been removed from VA employment due to violations of policy “relating to the delivery of safe and appropriate care” and...

Comprehensive Healthcare Inspection of the VA Central Iowa Health Care System in Des Moines

2024
23-00096-122
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Central Iowa Health Care System, which includes the Des Moines VA Medical Center...

Scheduling Error of the New Electronic Health Record and Inadequate Mental Health Care at the VA Central Ohio Healthcare System in Columbus Contributed to a Patient Death

2024
23-00382-100
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) reviewed concerns related to the care of a patient who died by accidental overdose approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus (facility). The OIG evaluated staff’s failure to conduct minimum...

Inadequacies in Patient Safety Reporting Processes and Alleged Deficient Quality of Care Prior to a Patient’s Foot Amputation at the Edward Hines, Jr. VA Hospital in Hines, Illinois

2024
23-01746-112
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, to assess an allegation that deficient quality of care resulted in a patient’s foot amputation.The patient told facility primary care staff about falling at...

Sterile Processing Service Deficiencies and Leaders’ Response at the Carl Vinson VA Medical Center in Dublin, Georgia

2024
22-01315-90
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

The VA Office of Inspector General (OIG) substantiated allegations from January 2022 that employees did not properly reprocess reusable medical equipment (RME) within the facility’s Sterile Processing Service (SPS). Facility leaders halted all endoscope usage, as well as stopped surgeries and...

Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia

2024
23-00012-136
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Martinsburg VA Medical Center and multiple outpatient clinics in Maryland, Virginia...

Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming

2024
23-00122-118
Inspection / Evaluation
Department of Veterans Affairs OIG
Department of Veterans Affairs

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Cheyenne VA Medical Center and multiple outpatient clinics in Colorado, Nebraska...

Scheduling Challenges Within the New Electronic Health Record May Affect Future Sites

2024
23-03295-80
Other
Department of Veterans Affairs OIG
Department of Veterans Affairs

The new electronic health record (EHR) includes a scheduling system intended to enhance efficiency and user experience, minimize disruptions in the delivery of care, and standardize workflows that improve patient access. Having a scheduling system that routes patients to the appropriate providers in...

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