Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a request from the OIG Office of Investigations to review the care of a patient at the Perry Point VA Medical Center, Maryland. The patient died in the hospice unit after receiving a potential overdose of a pain medication solution (oxycodone). Pharmacy Service staff dispensed oxycodone solution in one bulk bottle for multiple patients, including the identified patient, rather than in unit doses, which contributed to processes that increased risks in all phases of medication management. Additionally, pharmacists inconsistently processed medication orders. The facility’s established process for administering oxycodone solution contributed to additional risk as nurses did not have tools to accurately measure the solution. Facility leaders and patient safety program staff failed to recognize the inherent risks in medication administration and did not evaluate the patient’s death after receiving a potential medication overdose to determine the causes, system issues, and associated risks. Facility staff did not disclose the potential overdose to the patient’s family, conduct a root cause analysis or a peer review, or report it as an Adverse Drug Event to gain further understanding of the reasons and identify possible actions that could be taken to mitigate further risk. Facility staff did not follow requirements for ensuring recent acute care experience when hiring the nurse who administered the potential overdose and did not ensure the nurse’s competency related to the administration of this high-alert medication. Due to the identified medication management issues, the OIG was unable to determine whether the potential overdose contributed to the patient’s death. The OIG made eight recommendations related to evaluating and addressing the inaccuracies and risks involved with use of bulk bottles of oxycodone solution, quality review of the patient’s death, nurse hiring, and competencies processes.

The OIG investigated allegations that Smith & Marrs, Inc., an oil and gas production company, failed to report mineral production and sales from Federal leases located in New Mexico, which resulted in a loss of royalties owed to the U.S. Department of the Interior (DOI). We conducted the investigation jointly with the Bureau of Land Management’s (BLM) Special Investigations Group. We found that Smith & Marrs, Inc., failed to properly report oil and gas production and sales from Federal leases, which resulted in an underpayment of royalties and late payment interest. We then coordinated with ONRR officials to determine the total loss of royalties and interest, and ONRR sent Smith & Marrs payment requests for royalties due and late payment interest, which amounted to approximately $158,000. ONRR subsequently confirmed they had received full payment from Smith & Marrs.We referred our investigative findings to the U.S. Attorney’s Office for the District of Colorado, which declined prosecution.

Two executives at a textile company, based in Milford, Delaware, pleaded guilty to federal program bribery charges in U.S. District Court in February.Donald Crothers, the company’s vice president for marketing and contract administration, and John Gonzales, the company’s executive vice president and chief financial officer, pleaded guilty for their roles in a bribery scheme to secure Amtrak contracts for seat cushions. The executives bribed former Amtrak employee, Timothy Miller, then a Lead Contract Administrator, to steer four fleet maintenance contracts to their company in exchange for approximately $20,000 in bribes, trips, and other items of value. Crothers pleaded guilty on February 4, 2019, and Gonzales’ guilty plea came the following day.A cross-agency team of special agents from Amtrak OIG, the FBI, and the U.S. Department of Transportation OIG conducted the investigation that resulted in the charges.

An Amtrak Passenger Conductor, two Assistant Passenger Conductors, and an Usher/Gateman were disciplined for policy violations on February 5, 2019. The employees allowed and/or assisted non-ticketed passengers to receive unauthorized free travel aboard company trains on several occasions, generally at the request of other Amtrak employees. The employees received suspensions ranging from four to five days each.