Federal Reports

The VA Office of Inspector General (OIG) determined whether Veterans Health Administration (VHA) emergency department oversight ensured patients received emergency care services in a timely manner and whether facilities made any needed improvements to the patient flow process, which is how patients move through a facility from arrival to discharge or admission. Emergency departments measure timeliness using software that records this process. Some 2.3 million patients visit VHA’s 110 emergency departments each year.The data is necessary for VHA to determine how long patients waited to be seen, treated, and discharged. The OIG found data were inconsistently entered and contained inaccuracies. The OIG recognizes that emergency department staff may provide care first out of necessity before documenting it. However, data problems hindered identification of needed improvements in the patient flow process and the effectiveness of corrective action plans.The OIG found VHA’s data and evidence in patients’ electronic health records indicated that some patients with the most critical needs did not always receive emergency care within VHA timeliness thresholds. While the patients assessed in this audit were not found to have experienced clinically significant adverse outcomes due to their wait, VHA can improve its monitoring of the data for the patients most at risk.The OIG also identified possible data manipulation by the Baltimore VA Medical Center emergency department director that made it appear patient discharge or admission times were shorter than actual wait times. The director has since been replaced.The OIG made five recommendations to improve VHA’s emergency department oversight, including ensuring the Baltimore VA Medical Center reevaluates its corrective action plan, training staff on how to accurately record triage times, strengthening reliability reviews to improve data accuracy, establishing routine oversight for data reliability, and monitoring data of patients with the most severe needs receiving emergency care.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. The OIG identified concerns related to inaccurate electronic health record (EHR) documentation and an inadequate facility review of the patient’s care.The OIG substantiated that improper feeding during lunch by a CLC RN contributed to the death of a patient. Approximately five hours after being fed lunch when the patient was intubated, a piece of chicken was removed from the patient’s airway. A code team physician documented two EHR notes indicating a dimension of the chicken as .8 cm in one note and 8 cm in the second note. The OIG was unable to determine the exact size of the chicken but based on the information available, concluded that the chicken did not have a dimension of 8 cm but was larger than an appropriate size to feed to the patient.CLC nursing staff did not include accurate meal consumption documentation on the day at issue. Two staff members entered an EHR note which contained differing amounts of food the patient ate at breakfast. There was no documentation the patient ate lunch.The OIG determined that facility leaders did not complete a comprehensive review of the event. The Cardiopulmonary Resuscitation Subcommittee completed an insufficient review of the code by not determining the accuracy of the EHR documentation. No staff member submitted an incident report of the adverse clinical outcome. A clinical disclosure was completed but not an institutional disclosure.The OIG made seven recommendations to the Facility Director related to nursing competencies and training, feeding documentation, review of the patient’s care, committee oversight, incident reports, and institutional disclosure.

Information technology controls protect VA systems and data from unauthorized access, use, modification, or destruction. The VA Outpatient Clinic in Austin, Texas, is VA’s largest freestanding outpatient clinic— conducting almost 300,000 outpatient visits annually. The OIG inspected this clinic to determine whether it was meeting federal guidance in four security control areas related to configuration management, physical security, security management, and access controls.The team identified security deficiencies in the clinic’s configuration management controls related to component inventory and vulnerability and patch management. Although the inspection team and VA’s Office of Information and Technology (OIT) both used the same vulnerability scanning tools, OIT did not detect 150 of the 246 vulnerabilities the team identified. OIT’s standard vulnerability identification process and scans were ineffective. The poor component inventories and vulnerability management contributed to inadequate patch management. Without these controls, VA may be placing critical systems at unnecessary risk of unauthorized access, alteration, or destruction.The team also discovered three hard drives that potentially held personally identifiable information and personal health information that were not labeled or processed for sanitization. Media protection deficiencies like these increase the risk of unauthorized disclosure of veterans’ information.The team did not identify deficiencies with the maintenance, physical, and environmental security controls or security management and access controls. The clinic’s existing policies and procedures addressed these areas, and no recommendations were made for them.The OIG recommended maintaining an accurate inventory, implementing a more effective patch and vulnerability management program, distributing the media protection standard operating procedure, and ensuring compliance with the procedure’s labeling and sanitization provisions.

Due to the importance of switching and clearances being performed safely to avoid injuries and to minimize the possibility of unscheduled outages or equipment damage, we performed an evaluation to determine if switching and clearances, required training, and audits were performed in compliance with Transmission and Power Supply’s switching and clearance procedures. We determined the selected procedural requirements for requesting and tracking of switching and clearances were generally performed in accordance with procedures. We could not assess most procedural requirements related to preparation and performance of switching orders because field personnel performing the work do not always submit the completed switching order. However, we identified several instances where switching order steps were not performed in sequence as required. We also determined employees who performed key functions received required training; however, tracking of training could be improved. In addition, while clearance audits were completed by the appropriate personnel within the required time frames, their effectiveness could be increased.

We confirmed that 15 high-risk disaster relief purchases made by the BLM and the NPS were allowable and supported by DOI and bureau policy.