Federal Reports

Semiannual Report to Congress: April 1, 2020 - September 30, 2020

OIG reviewed USDA’s compliance with the covered agency responsibilities outlined in the Geospatial Data Act.

Report on Audit of Federal Trade Commission Personnel Security and Suitability Program Processes

Management Challenges and Performance Challenges

The VA Office of Inspector General (OIG) evaluated allegations that facility leaders failed to address nurse staffing shortages yet continued to accept resident admissions and that the shortages contributed to adverse events, environment of care concerns, and infection control issues. The OIG further assessed allegations that the Community Living Center (CLC) did not have 24-hour housekeeping aides available, was dirty and infested with flying insects, CLC staff did not wash their hands, the CLC was quarantined more than two times during a 12-month period, a contracted staffing company (registry agency) was not meeting the requested number of nursing assistants (registry staff), and registry staff did not have access to residents’ electronic health records (EHRs). The OIG substantiated that facility leaders failed to address CLC nurse staffing shortages yet continued to accept admissions. The OIG was unable to determine if insufficient CLC staffing levels led to adverse events. However, the OIG identified a higher potential for an adverse clinical outcome related to a missing resident. The facility missed an opportunity to further analyze the event. Facility leaders reduced the number of operating beds without VHA authorization. Managers increasingly relied on registry staff, but the registry agency inconsistently supplied the requested number of staff. The Staffing Methodology Coordinator had insufficient knowledge and used inaccurate staffing targets. The OIG substantiated that 24-hour Environmental Management Service was not available; CLC staff were not consistently meeting the facility hand-hygiene compliance goal; one or both CLC floors closed to admissions and visitors between 2018 and 2019, but CLC staff followed identified processes to minimize additional exposures; and registry staff did not have access to EHRs and could not document care. The OIG did not substantiate that the CLC was dirty but substantiated the presence of flying insects. The OIG made ten recommendations to the facility director.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns that the failure to follow pharmacy and nursing policies and procedures may have contributed to a patient’s death at the Southeast Louisiana Veterans Health Care System in New Orleans (facility). Following a code blue on the medical-surgical unit, a patient with multiple medical conditions was transferred to the intensive care unit (ICU). The patient’s provider ordered intravenous (IV) fentanyl (a controlled substance) and IV norepinephrine. Due to the patient transferring to the ICU, new medication orders entered previously were discontinued. As a result, an ICU nurse was unable to scan the IV fentanyl label. Another ICU nurse called the pharmacy for a new IV fentanyl label. A pharmacy staff member failed to follow the intent of the facility policy and sent an unattached IV norepinephrine label to the ICU. Subsequently, another ICU nurse incorrectly affixed the IV norepinephrine label to the IV fentanyl bag. The ICU nurse failed to follow facility policy by not verifying the patient and medication information prior to affixing the incorrect label. The patient received the IV fentanyl, mislabeled as IV norepinephrine, at rates not prescribed. ICU nursing staff also failed to follow the infusion rate orders and did not assess the effectiveness of the medication or complete documentation to ensure an accurate record of medications administered. Additional concerns identified during the OIG inspection included an unsecured IV controlled substance and the facility did not conduct a thorough review of the medication error. The OIG made eight recommendations related to unaffixed medication labels; medication administration, medication orders, and compliance with Veterans Health Administration and facility policies regarding high-alert and high-risk medications; security of controlled substances; submitting Joint Patient Safety Reports; peer review; and institutional disclosure.