Federal Reports

Our 2022 organizational assessment highlights our significant accomplishments in overseeing the DOI’s programs and operations.

The Office of Enforcement and Compliance Assurance, or OECA, is not on track to achieve ten (25 percent) of the 40 measures and deliverables in its National Compliance Initiative, or NCI, strategic plan.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding a primary care provider (provider) potentially falsifying blood pressure readings (blood pressures) at the North Las Vegas VA Medical Center (facility) in Nevada.The OIG determined the provider knowingly documented false blood pressures in patients’ electronic health records (EHRs) during VA Video Connect (VVC) visits. The provider attributed the falsifications to the belief that the VVC template required documentation of a blood pressure when a blood pressure was not obtained and to a lack of VVC training. The OIG confirmed that the VVC template did not require documentation of blood pressures and determined the provider completed required VVC trainings.The provider reported patients were not harmed by the falsifications because mitigation strategies were used. From a review of a sample of EHRs, the OIG determined the provider did not use the mitigation strategies with most patients; however, the OIG did not find evidence that any patients experienced an adverse clinical outcome as a result of the false blood pressures.Upon learning of the provider’s falsification of blood pressures, facility leaders took actions that included retraining and facilitating an EHR review. Despite the retraining, the provider continued to display difficulty demonstrating the use of technology and locating the VVC template. The OIG evaluated a sample of EHRs from the facility’s review and found that not all entries with a blood pressure of 120/80 were clinically reviewed and amended. Additionally, the OIG determined that facility leaders failed to initiate state licensing board reporting processes.The OIG made five recommendations to the Facility Director related to verifying the provider’s ability to complete and document VVC visits, considering administrative action, initiating state licensing board reporting processes, and ensuring the provider’s blood pressure entries in EHRs are reviewed and amended.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a patient received poor care in the Emergency Department at the Baltimore VA Medical Center (facility) in Maryland, which resulted in an amputation at the patient’s left forearm at a non-VA hospital days later. The OIG identified additional concerns related to the patient’s primary care provider not maintaining the patient’s problem list in the electronic health record and Emergency Department providers’ failure to address the patient’s second chief complaint of knee pain.The OIG reviewed the care the patient received at the facility’s Emergency Department on two consecutive days in early fall 2021. During the first visit, the patient, with a medical history of poorly controlled type II diabetes, presented to the facility complaining of left hand pain with a ring stuck on the middle finger after sustaining a fall. The following day, the patient returned with left hand pain; redness, swelling, and a superficial open wound to the finger; and knee pain.The OIG substantiated the patient received poor Emergency Department care during the second visit when a physician assistant failed to obtain laboratory studies for a patient with diabetes and a hand infection, to complete a comprehensive clinical assessment of the patient, and to document a clinical consultation with an attending physician. Additionally, the overseeing attending failed to identify concerns with the physician assistant’s documented care of the patient. The OIG determined these failures may have contributed to the patient’s amputation. An institutional disclosure was conducted, which included a plan for staff training.The OIG made four recommendations to the Facility Director related to ensuring Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints, evaluation of clinical consultation processes, staff training, and maintaining problem lists.