The VA Office of Inspector General (OIG) conducted a healthcare inspection of the VA Nebraska-Western Iowa Health Care System (facility) in Omaha from November 2024 through May 2025, following a congressional request to evaluate allegations related to the inpatient mental health unit’s environment of care. The OIG also evaluated allegations from another complainant regarding unit staffing and identified additional concerns related to training, policy guidance, and oversight.
The OIG substantiated facility leaders did not ensure adequate night lighting in patient rooms, which may affect patients’ sleep and hinder staff’s ability to conduct safety rounds. The OIG also substantiated the unit was not consistently staffed with the required number of employees trained in therapeutic containment for high-risk areas, placing patients and employees at risk. Although the OIG did not substantiate allegations that the unit was unclean and restroom doors did not lock, the OIG found female patients were unable to access the restroom without staff assistance.
The OIG found nursing leaders did not (1) develop a required patient safety rounding standard operating procedure, increasing the risk of inconsistent observation practices, and (2) ensure a clear process for using a risk for violence assessment, contributing to the inability to determine required staffing.
Additionally, facility leaders did not (1) consistently report root cause analysis action items, which may result in leaders being unaware of opportunities to improve care, and (2) notify Veterans Integrated Service Network (VISN) 23 leaders of bed closures exceeding 60 days, misrepresenting available bed capacity.
The Under Secretary for Health concurred with 2 OIG recommendations related to high-risk workplace staffing guidance; the VISN Director concurred with 1 recommendation regarding oversight of bed changes; and the Facility Director concurred with 10 recommendations regarding unit lighting, rounding procedures, mitigation planning, staffing and training requirements, and root cause analysis reporting.
NE
United States
