Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to review telemetry medical instrument technician (MIT) actions and leaders’ response to allegations that an MIT (MIT A) changed patient alarm settings and placed a communication device on “DO NOT DISTURB” for long periods. The OIG identified an additional MIT (MIT B) who possibly engaged in similar practices.The OIG found that while monitoring a telemetry patient (Patient A), MIT A failed to document notifying nursing staff of Patient A's oxygen desaturation alarms (patient event A) and a registered nurse failed to document a change in Patient A’s condition after staff found Patient A unresponsive and pulseless. Further, the OIG found another patient (Patient B) reported experiencing cardiac symptoms (patient event B) to nursing staff. There was a delayed notification of the event to nursing staff due to reports that MIT B turned off the audio of patient B’s monitoring alarms.The OIG found that telemetry nursing leaders failed to ensure and document MITs adherence to clinical alarm monitoring expectations.The OIG found that facility staff did not enter a patient safety report in the Joint Patient Safety Reporting system for patient event A despite the event involving a patient death. Although a patient safety report was entered for patient event B, a patient safety manager rejected the event, which inhibited further investigation by patient safety staff.The OIG found the Associate Director Patient Care Services failed to provide oversight of clinical alarm management, which could result in an increased risk for the occurrence of patient safety events.The OIG made six recommendations to the Facility Director related to medical record documentation, review of the telemetry program, patient safety event reporting, institutional disclosure, and clinical alarm management.

We found that the bureaus generally did not properly inventory or inspect radio infrastructure as required by the DOI OCIO directive.

The Defense Nuclear Facilities Safety Board (DNFSB) Office of the Inspector General (OIG) conducted this audit because (1) the OIG last audited the DNFSB’s Freedom of Information Act (FOIA) program in 2014; and, (2) the FOIA Improvement Act of 2016 changed processes, roles, and responsibilities concerning federal agency FOIA programs.The Defense Nuclear Facilities Safety Board’s FOIA request processing and communications are sometimes untimely, inconsistent with FOIA requirements, or insufficient to apprise requesters of the reasons for the agency’s decision. Due to outdated information, agency FOIA decisions may conflict with statutory requirements or be inconsistent with statutory requirements.Agency processes must be documented and have adequate controls to ensure data reliability. However, FOIA program records and information are often missing or erroneous. This occurs because the DNFSB lacks controls for its FOIA request management tool, and also lacks an electronic records repository system. As a result, the agency’s FOIA program knowledge management and public reporting could be compromised.The time and materials service contract used for FOIA program support identifies FOIA-specific terms, but some terms were not met. This occurred because the Contracting Officer’s Representative (COR) was relatively inexperienced and inadequately supported, and the agency’s FOIA program staff did not adequately communicate with the COR. This is important because time and materials contracts are considered high-risk, and thus require enhanced oversight by experienced program staff.This report makes eight recommendations intended to improve and strengthen the agency’s FOIA program.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service’s mission is to provide timely, reliable, secure, and affordable mail and package delivery to more than 160 million residential and business addresses across the country. The U.S. Postal Service Office of Inspector General (OIG) reviews delivery operations at facilities across the country and provides management with timely feedback in furtherance of this mission.

The U.S. Postal Service needs effective and productive operations to fulfill its mission of providing prompt, reliable, and affordable mail service to the American public. It has a vast transportation network that moves mail and equipment among about 330 processing facilities and 31,100 post offices, stations, and branches. The Postal Service is transforming its processing and logistics networks to become scalable, reliable, visible, efficient, automated, and digitally integrated. This includes modernizing operating plans and aligning the workforce; leveraging emerging technologies to provide world-class visibility and tracking of mail and packages in near real time; and optimizing the surface and air transportation network. The U.S. Postal Service Office of Inspector General (OIG) reviews the efficiency of mail processing operations at facilities across the country and provides management with timely feedback to further the Postal Service’s mission.