Federal Reports

The OIG investigated allegations that a Bureau of Indian Affairs (BIA) senior official approved or directed the approval of two drawdowns totaling approximately $3.1 million from an Operation, Maintenance, and Replacement (OMR) Trust Fund designated for a regional rural water system (RWS) at a time when the RWS was years from completion and had few, if any, OMR expenses. There was increased scrutiny of the senior official’s involvement because he was affiliated with a group that would be served by the RWS.Our investigation determined that a subordinate of the senior official, not the senior official, authorized the drawdowns. The senior official had recused himself from the matter and had no involvement in either drawdown.We also found that the subordinate failed to perform required due diligence before approving the drawdowns. After questions arose following the first drawdown, the subordinate of the senior official was directed to consult with BIA’s Office of Facilities Management and Construction (OFMC) prior to any future drawdowns, however, he failed to consult with OFMC prior to the second drawdown. The subordinate acknowledged he failed to perform the required due diligence and retired from the BIA before the completion of our investigation.The United States Attorney’s Office for the District of Montana declined prosecution.

The VA Office of Inspector General (OIG) assessed the reliability of wait time data and evaluated whether Veterans Integrated Service Network (VISN) 15 provided timely access to health care within its medical facilities and through Choice, and whether they appropriately managed consults. The OIG estimated that new patients waited an average of about 18 days, and 18 percent of the appointments for new patients at VISN 15 facilities had wait times longer than 30 days. This was higher than the estimated 10 percent that the Veterans Health Administration’s (VHA) electronic scheduling system showed. Staff did not correctly record clinically indicated dates for about 38 percent of the new patient appointments, which understated wait times by about 15 days. Inaccurate wait time data resulted in veterans not being identified as eligible for Choice. With respect to veterans in VISN 15 who received care through Choice, the OIG estimated that the overall average wait time was 32 days. The audit estimated that 41 percent of the appointments had wait times longer than 30 days, and those veterans waited an average of 58 days. Facilities did not have adequate procedures to monitor the aging of veteran referrals from facilities to TriWest, and did not consistently monitor the aging of the authorized Choice care. Regarding consults, facility staff discontinued or canceled an estimated 27 percent inappropriately, which led to veterans experiencing additional delays, or not receiving the requested care. Clinicians and staff were still unclear on specific consult management procedures. The Office of Healthcare Inspections identified clinical concerns with six patients, and determined that one patient likely had an adverse outcome as a result of a delay in care. The OIG made 11 recommendations—three to the Office of the Under Secretary for Health and eight to the VISN 15 Director. VHA and VISN 15 provided responsive action plans.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the circumstances of a patient’s death involving alleged mismanagement of the patient’s resuscitation (Event) at the Buffalo VA Medical Center (Facility), Buffalo, New York, and actions taken by Facility leaders subsequent to the death. The Facility Director contacted the OIG to report a registered nurse (RN 1) found the patient unresponsive and did not “call a code” because he/she feared cardiopulmonary resuscitation (CPR) would traumatize the patient’s body. The OIG substantiated RN 1 did not “call a code” after finding the full-code patient unresponsive. The OIG determined • RN 1 and a respiratory therapist (RT) acted outside their scopes of practice and violated policy when they announced the patient was dead, which influenced others not to take action; • A telemetry RN (RN 2) failed to call for assistance and abandoned the telemetry desk during the Event; • A licensed practical nurse failed to call for assistance and initiate CPR; • Telemetry monitoring failures contributed to the delayed response to the Event; • RN 1 failed to document the patient’s lung assessment and the RT failed to assess the patient’s respiratory status, before and after a scheduled respiratory treatment; and • The Facility’s Performance Manager’s conversation with the patient’s family could have been misunderstood. The OIG identified administrative concerns related to Facility leaders’ responses to the Event. Specifically, Facility leaders did not immediately remove involved staff from direct patient care, conduct a timely Administrative Investigation Board and Root Cause Analysis, submit an Issue Brief to the Veterans Integrated Service Network, and pursue notifying the patient’s family or personal representative. The OIG found Facility staff failed to preserve the patient’s telemetry data. The Facility did not have a policy and Veterans Health Administration has not provided guidance about preservation of evidence after an adverse event. The OIG made 10 recommendations.