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Report File
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Components
Veterans Health Administration
Report Number
24-00599-202
Report Description

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Signs and maps
     •    Emergency generator and fire door inspection and testing
     •    Environment of care committee meetings
     •    Mental Health Residential Rehabilitation Treatment Program area cleanliness
     •    Hands-free sanitizer dispensers
     •    Guidance for shelter-in-place supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Process to monitor the communication of test results
     •    Improvement actions from root cause analyses

Report Type
Inspection / Evaluation
Location

ID
United States

OR
United States

WA
United States

Number of Recommendations
9
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

02 No $0 $0

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

04 No $0 $0

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

05 No $0 $0

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

07 No $0 $0

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

08 No $0 $0

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

09 No $0 $0

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

Department of Veterans Affairs OIG

United States