Federal Reports

An Amtrak conductor based in Los Angeles, California, was terminated from employment on August 13, 2024, following an administrative hearing. Our investigation found that the employee violated company policies by failing to report his arrest for driving under the influence.

An Amtrak train attendant based in Charlotte, North Carolina, signed a civil settlement agreement on August 13, 2024, with the U.S. Attorney’s Office, Eastern District of North Carolina. The employee agreed to pay a total of $10,800 in settlement, restitution, and penalties to the Railroad Retirement Board (RRB). Our investigation found that the employee worked a second job while receiving RRB sickness benefits. We found that between July 19, 2021, and January 16, 2022, the employee submitted at least 13 false claims to the RRB for sickness benefits. As a result, the employee received $8,282 in benefits to which she was not entitled.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and placed a communication device on “DO NOT DISTURB” for long periods. The OIG identified an additional MIT (MIT B) who possibly engaged in similar practices.The OIG found that while monitoring a telemetry patient (Patient A), MIT A failed to document notifying nursing staff of Patient A's oxygen desaturation alarms (patient event A) and a registered nurse failed to document a change in Patient A’s condition after staff found Patient A unresponsive and pulseless. Further, the OIG found another patient (Patient B) reported experiencing cardiac symptoms (patient event B) to nursing staff. There was a delayed notification of the event to nursing staff due to reports that MIT B turned off the audio of patient B’s monitoring alarms.The OIG found that telemetry nursing leaders failed to ensure and document MITs adherence to clinical alarm monitoring expectations.The OIG found that facility staff did not enter a patient safety report in the Joint Patient Safety Reporting system for patient event A despite the event involving a patient death. Although a patient safety report was entered for patient event B, a patient safety manager rejected the event, which inhibited further investigation by patient safety staff.The OIG found the Associate Director Patient Care Services failed to provide oversight of clinical alarm management, which could result in an increased risk for the occurrence of patient safety events.The OIG made six recommendations to the Facility Director related to medical record documentation, review of the telemetry program, patient safety event reporting, institutional disclosure, and clinical alarm management.

We found that the bureaus generally did not properly inventory or inspect radio infrastructure as required by the DOI OCIO directive.