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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for Global Media (f/k/a Broadcasting Board of Governors), Department of State
Semiannual Report to The Congress, October 1, 2021 - March 31, 2022
Office of the Inspector General of the Intelligence Community
Report Description
(May 2022) The Office of the Inspector General of the Intelligence Community (IC IG) recently released its Semiannual Report to the Director of National Intelligence (DNI) and Congress for the period of October 1, 2021, through March 31, 2022. The National Security Act of 1947 (as amended) requires the IC IG to prepare and submit to the DNI a classified and, as appropriate, unclassified report summarizing the work of the IC IG for the preceding six-month period.
The Office of the Inspector General for the Nuclear Regulatory Commission and the Defense Nuclear Facilities Safety Board presents its Semiannual Report to Congress. This report highlights the work the OIG has completed from October 1, 2021, to March 31, 2022.
Failure to Provide Emergency Care to a Patient and Leaders’ Inadequate Response to that Failure at the Malcom Randall VA Medical Center in Gainesville, Florida
The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility), after the patient’s death at the University of Florida Health Shands Hospital (Shands).The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.The Emergency Department nurses disregarded EMS personnel’s patient status report, failed to recognize the patient’s emergency medical condition, and inaccurately assessed the patient’s condition. The OIG identified deficiencies in nursing competencies and concerns regarding the replication of competency assessments.The OIG learned that the facility had prior instances of Veterans Health Administration Emergency Medical Treatment and Labor Act (EMTALA)-related policy violations in 2019, resulting in Emergency Department staff being required to complete EMTALA-related training. The OIG found the actions implemented by facility leaders to address concerns were not effective in preventing the occurrence of additional patient incidents, and delays in the provision of emergency care to patients continued.The OIG made one recommendation to the Veterans Integrated Service Network Director regarding consideration of administrative action and reporting to state licensing board(s). The OIG made four recommendations to the Facility Director related to the prioritization of emergency patient care and nursing competencies.
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 2: New York/New Jersey VA Health Care Network in Bronx, New York, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The VISN had a stable leadership team, with the Quality Management Officer and Chief, Human Resources Officer permanently assigned prior to the integration of VISNs 2 and 3 in 2015. Selected employee satisfaction survey scores indicated that some VISN leaders had opportunities to improve employee perceptions of servant leadership, respect, discrimination, and psychological safety. Inpatient experience survey scores were lower than VHA national averages but outpatient ratings were higher. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks, with wait times over 20 days at one medical center and clinical vacancies in certain specialties. Opportunities existed to improve executive leadership oversight of facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.The OIG issued four recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials review process(2) Environment of Care• Annual reviews(3) Women’s Health• Lead women veterans program manager appointment• Annual site visits