Federal Reports

To understand the nature of cooperation between the FBI and HSI fully, weused a two-part methodology. First, in November 2017 we deployed ananonymous online survey to all 2,948 FBI and HSI agents assigned to Southwestborder locations to gather their experiences and perceptions of cooperation. Wereceived 980 complete responses, a 33 percent response rate. The FBI’s responserate was 23 percent (291 of 1,245), and HSI’s was 40 percent (689 of 1,703).Second, we conducted interviews with 246 DOJ and DHS personnel, primarily fromthe FBI, HSI, and U.S. Attorney’s Offices (USAO). We traveled to 10 Southwestborder locations to interview agents, Intelligence Analysts, and Assistant U.S.Attorneys who prosecute FBI and HSI cases to gain a better understanding of thereported problems

To illustrate the importance of individuals coming forward to report waste, fraud, abuse, and misconduct to Offices of Inspector General (OIG), we used the search function on Oversight.gov and identified many examples of OIG investigations, audits, and reviews initiated or advanced because of a whistleblower disclosure. We present a sample of these reports and also summarize OIG efforts to protect whistleblowers from unlawful retaliation. Our whistleblower resources page on Oversight.gov provides more information on where to report of waste, fraud, abuse, or retaliation. Click the link below for more information.

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

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate factors that may have impacted or contributed to the unexpected death of a ventilator-dependent patient on the Spinal Cord Injury (SCI) unit at the VA San Diego Healthcare System and to follow-up on the facility’s response. The OIG could not determine what the ventilator settings were at the time of the patient’s death, because facility staff who inspected the ventilator immediately thereafter changed the settings to check whether alarms were functional and then reportedly returned the settings to the previous levels. The OIG determined the facility did not implement risk mitigation strategies for the use of the in-line Passy-Muir® Valve (PMV) on ventilated patients. The facility did not have a back-up monitoring plan when the ventilator alarms were off, patient criteria to determine when the valve should be removed, policies for facility staff and patient/family education on the use of the PMV, policies or procedures for monitoring and documenting ventilator and alarm settings while using the PMV, or a policy to use anti-disconnect devices. At the time of the patient’s death, the SCI unit used an outdated nurse call system that required the use of a splitter to connect the ventilator to the call system, none of the respiratory therapy staff had training or competency assessments related to PMV use, staff failed to report the patient’s ventilator tubing disconnections through the Patient Safety reporting system, and SCI leaders failed to follow the standard operating procedure for the management of clinical alarms. The OIG made five recommendations related to policy and training for use of the PMV on the SCI unit and the anti-disconnect device, potential issuance of a National Patient Safety Advisory, training for reporting patient safety issues, and reviewing clinical alarms according to facility policies.