Federal Reports

See the additional details link below for the full report, report summary, multimedia or any agency follow-up.

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations that coordination and quality of care issues contributed to a delay in transfer and led to a patient death shortly after transfer from the Robert J. Dole VA Medical Center (facility) in Wichita, Kansas, to a community hospital. The OIG substantiated that coordination and quality of care issues in the management of a patient who presented to the facility’s Emergency Department with acute coronary syndrome (ACS) symptoms contributed to the patient’s death. The Emergency Department physician mismanaged the patient’s care by failing to initiate a timely transfer to a hospital capable of providing percutaneous coronary intervention (PCI). The patient presented to the Emergency Department in early 2019 with ACS symptoms. The physician contacted a facility cardiologist who advised transfer to a community hospital capable of PCI. The physician made two calls to a community hospital to initiate the transfer. The first call was to contact the patient’s personal community cardiologist. The second call, placed 50 minutes after the patient’s arrival to the facility Emergency Department, was to the on-call cardiologist at the community hospital who accepted the patient for admission. During transport, the patient became unstable and died soon after arriving at the community hospital. The OIG concluded that failure to transfer the patient for PCI within 30 minutes of arrival limited the patient’s chances for the best possible outcome. The facility conducted a review of the patient’s care but did not determine any contributing factors that led to the transfer delay or take actions to improve the emergent transfer process. The OIG made one recommendation to the Veterans Integrated Service Network Director related to peer review and nine recommendations to the Facility Director related to staff training, interfacility transfers, policy updates, committee oversight, and institutional disclosure.

Pursuant to the VA Choice and Quality Employment Act of 2017, the Office of Inspector General (OIG) conducted a review to identify clinical and nonclinical occupations experiencing staffing shortages within the Veterans Health Administration (VHA). This is the seventh iteration of the staffing report and the third report evaluating facility-level data. The OIG evaluated severe occupational staffing shortages identified through surveying medical center directors and compared this information to the previous two years. The OIG found that 95 percent of VHA facilities identified at least one severe occupational staffing shortage. The total number of identified severe occupational staffing shortages was 2,430. The most frequently cited occupational shortages were in the Medical Officer and Nurse occupations—derived from assignment codes used by VHA to designate specialties within the corresponding Office of Personnel Management occupational series. Sixty percent of facilities identified Psychiatry as the most frequently reported clinical severe occupational staffing shortage. Custodial Worker was the most frequently reported nonclinical occupation by 47 percent of facilities. Practical Nurse was the most frequently reported Hybrid Title 38 occupation. The OIG observed annual decreases in the overall number of severe shortages since fiscal year 2018. The number of occupations reported by at least 20 percent of facilities decreased from 30 in fiscal year 2018 to 17 in fiscal year 2020. The number of facilities reporting no severe occupational shortages increased from zero to seven over the last three years. One facility reported zero severe occupational staffing shortages in fiscal year 2020; however, in fiscal years 2018 and 2019, that facility reported the highest overall number of shortages across VHA. The OIG made no recommendations.

To view the report, please click on the link below.

U.S. Customs and Border Protection (CBP) did not adequately safeguard sensitive data on an unencrypted device used during its facial recognition technology pilot (known as the Vehicle Face System). A subcontractor working on this effort, Perceptics, LLC, transferred copies of CBP’s biometric data, such as traveler images, to its own company network. The subcontractor obtained access to this data without CBP’s authorization or knowledge, and compromised approximately 184,000 traveler images from CBP’s facial recognition pilot. Later in 2019, the Department of Homeland Security experienced a major privacy incident, as the subcontractor’s network was subjected to a malicious cyber attack. While CBP and DHS took immediate action to mitigate the data breach, we attribute this incident to the subcontractor violating numerous DHS security and privacy protocols for safeguarding sensitive data. Consequently, this incident may damage the public’s trust in the Government’s ability to safeguard biometric data, and may result in travelers’ reluctance to permit DHS to capture and use their biometrics at U.S. ports of entry. We made three recommendations to aid CBP in addressing the vulnerabilities that caused the 2019 data breach, and to better mitigate future incidents through greater oversight of third-party partners. CBP concurred with all three recommendations.