Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to-one observation status (1:1) for suicidal ideation, started a Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) protocol for treatment of alcohol withdrawal symptoms, and entered a consult to the psychiatry service. Four days later, the patient was found in the bathroom hanging from a necklace, having died by suicide.The OIG found that staff did not follow policy requirements to remove the patient’s belongings or reduce environmental risks. Additionally, a nurse failed to conduct a warm handoff as required for the completion of a Comprehensive Suicide Risk Evaluation (CSRE) after completing a positive suicide risk screening. The psychiatrist completed a telemental health evaluation of the patient but did not complete the required CSRE. On the third day of admission, the psychiatrist did not reassess the patient before changing the patient’s 1:1 order to every 15-minute checks and did not sign the evaluation note within the required 24-hour time frame, leaving the assessment unavailable to other providers.Nursing staff documented CIWA-Ar assessments every 1–4 hours and administered lorazepam as ordered except for one error. The medical unit nurse manager reported addressing the error, and the error had no impact on the patient’s outcome.Facility leaders evaluated processes related to the care of the patient through actions that included a root cause analysis in accordance with Veterans Health Administration policy. The resulting action plans addressed concerns identified in this report.The OIG made four recommendations to the Facility Director related to clinical screenings and evaluations, timely documentation, and removing environmental risks.

The VA Office of Inspector General (OIG) reviewed an allegation that a patient experienced a delay in receiving basic life support (BLS) during a medical emergency on the grounds of the Carl T. Hayden VA Medical Center (facility) in Phoenix, Arizona, and later died at a community hospital.The OIG determined the patient experienced a delay in receiving BLS. The OIG learned of deficiencies related to the initiation of emergency medical care, including (1) conflicting facility policies that were inconsistent with Veterans Health Administration (VHA) requirements, (2) lack of layperson cardiopulmonary resuscitation (CPR) training, and (3) lack of an automatic external defibrillator (AED).Quality of care concerns were also identified, which included a discrepancy between the documented plan for a wearable cardioverter defibrillator (WCD) and the absence of an order for the device, and a failure to assess vital signs at an appointment preceding the medical emergency. The OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient.Facility leaders’ lack of response upon awareness of the event did not align with high reliability organization (HRO) principles and I CARE values. The OIG identified the patient safety manager did not facilitate a thorough investigation of the related patient safety report, which resulted in an inaccurate harm assessment. Additionally, the patient safety manager and Facility Director failed to ensure a timely review of the report and investigation.The OIG made 10 recommendations to the Facility Director related to congruence of facility policies and their alignment with VHA Directives, layperson CPR training, placement of AEDs at the facility, outpatient clinic compliance with vital signs completion, complaint review processes, communicating in alignment with HRO and I CARE values, training on patient safety reporting, and investigation and closure of patient safety reports.

We conducted a review to determine the Federal Student Aid office’s (FSA) actions to mitigate risks associated with the verification of identities in the FSA ID account creation process. Although we found that FSA had implemented controls to address identity verification risks associated with FSA ID account creation, it could take further actions by implementing preventive controls to better protect Title IV funds and the public from fraudulent activity. We found that approximately $27.3 million in Title IV funds was disbursed to suspected fraudulent FSA ID accounts. Further, although FSA has taken several steps to mitigate other risks to FSA ID accounts, these controls mitigate risks after the FSA ID account has been created and do not mitigate risk associated with the creation of the FSA ID account. We also identified a data reliability issue with the National Student Loan Data System data.