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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Louisville Healthcare System in Kentucky. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued 13 recommendations for VA to correct identified deficiencies in four domains: 1. Culture • Telephone system improvements 2. Environment of care • Exit signs • Detectable warning surfaces • Clean and safe patient care areas • Electrical cord management • Biological hazard signs • Biohazardous waste disposal • Liquid nitrogen use and storage • Environment of care trends, improvement plans, and outcome measures 3. Patient safety • Service-level workflows for test result communications • Test result communication policy • Test result communication performance metrics 4. Primary care • Panel sizes
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care concerns and inadequate quality reviews related to a patient’s death at the VA Greater Los Angeles Healthcare System (facility). The OIG determined that clinical staff did not timely recognize, address, and investigate changes in the patient’s clinical condition. Although the outcome may not have changed, not recognizing an emerging condition hindered clinical staff considering modifications to the plan of care and discussing the course of action with the patient and family.
The OIG identified several factors that contributed to staff not recognizing the patient’s deterioration and intervening accordingly. The resident physician ordered laboratory tests, but neither the resident nor attending physician reviewed or acted upon the patient’s abnormal laboratory values. The resident ordered stat imaging studies to assess abdominal pain and evaluate for infection; however, the resident, attending, and nursing staff did not ensure imaging completion.
Nurses missed early warning signs of the patient’s deteriorating condition by not conducting National Early Warning Score (NEWS) assessments as required or intervene, as expected, with elevated NEWS scores. Nurses did not complete shift assessments within the required time frames. The OIG identified an 11-hour gap in nursing documentation before the patient’s death. Nurses lacked accurate on-call provider contact information and attempts to reach the on-call provider to address the patient’s pain were unsuccessful.
Facility leaders did not conduct a comprehensive review of the events that occurred prior to the patient’s death and were unsuccessful in their attempts to conduct an institutional disclosure with the patient’s family.
The Facility Director concurred with and submitted action plans to address the OIG’s seven recommendations related to comprehensive reviews of the patient’s care, NEWS assessment training, nursing assessment compliance, patient care escalation processes, and disclosure efforts.
This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Detroit Healthcare System in Michigan. This evaluation focused on five key content domains: • Culture • Environment of care • Patient safety • Primary care • Veteran-centered safety net
The OIG issued six recommendations for VA to correct identified deficiencies in one domain: 1. Environment of care • Damaged furnishings • Maps for navigation • Clean equipment storage • Unobstructed hallways and exits • Defective equipment removal • Computer screen privacy filters
The VA Office of Inspector General (OIG) issued this preliminary result advisory memorandum to communicate a serious patient safety risk related to acute ischemic stroke (AIS) management at the Wm. Jennings Bryan Dorn VA Medical Center (facility) in Columbia, South Carolina. During a healthcare inspection, the OIG found that the facility’s AIS practices did not align with Veterans Health Administration (VHA) or facility policy, resulting in delays in diagnosis, evaluation, treatment, and disposition of patients with stroke symptoms. These concerns were shared with Veterans Integrated Service Network and facility leaders during a site visit on August 28, 2025, prompting immediate interim corrective actions.
To promote proactive risk mitigation across the enterprise, the OIG is broadly sharing this preliminary finding with other VHA facilities.
VHA Directive 1155(1) requires VA medical centers to maintain a protocol for emergent stroke management. The OIG found that the facility’s actual practices contradicted its own policy, which outlined a code stroke protocol, stroke team responsibilities, emergency department evaluation for all suspected AIS cases, and use of the VA National Telestroke Program. In practice, inpatient units lacked a stroke team or code stroke protocol, and patients were not transferred to the emergency department or evaluated by telestroke neurologists unless already in the emergency department.
The OIG observed a case in which intensive care unit staff failed to promptly respond to a suspected stroke, resulting in delayed imaging, neurology evaluation, and transfer to a community stroke center. The absence of a clear transfer protocol further hindered timely care.
During the site visit, the OIG advised facility leaders to take corrective actions by September 5, 2025. The facility has since developed a new standard operating procedure, initiated staff training, and plans to revise its policy. The OIG will continue monitoring progress and include full findings in the final report.
The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered throughout Readjustment Counseling Service (RCS).
This inspection evaluated leadership stability, morbidity and mortality reviews, and the high risk suicide flag (HRSF) SharePoint site within Midwest District 3.
There were no findings in leadership stability. The morbidity and mortality review identified that district leaders did not ensure reviews had the required RCS panel members and contained all required components. The HRSF review identified noncompliance with documentation requirements for high-risk client contacts and outcomes in both RCSNet and the HRSF SharePoint site. This noncompliance was attributed to unclear or insufficient guidance provided to staff. The OIG issued two recommendations for improvement to the District Director and one recommendation to the Chief Officer.
An Amtrak Trackman/Watchman based in Wilmington, Delaware, was terminated from employment on October 14, 2025, following an administrative hearing. Our investigation found that the employee violated company policies by shipping baggage on Amtrak trains while traveling by other means, driving a company-leased vehicle without a valid license, using his company-leased vehicle for personal travel, and leaving work without authorization. The employee also violated company policy by being dishonest with our agents during his interview.
