Veteran Oversight Now VA OIG

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from March 2024.      
 
“Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.”
 
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
 
Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024.      
 “It overall affects the care that the patients receive. Some of the care just wasn’t available anymore because they didn’t have the cardiologists available.”
 
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024.      
 
“The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.”
 
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
 
Related Report: Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona

In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the original 12. He also discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2023. This edition also includes highlights of the VA OIG’s work from October 2023.      
 
“As only the sixth Senate-confirmed VA Inspector General over the past 45 years, it is truly an honor and privilege to work on behalf of veterans and taxpayers. It is also a real honor and privilege to work with all of our staff to meet our mission of meaningful independent oversight. We had a great fiscal year 2023 and we look forward to an even more impactful fiscal year 2024.” – VA Inspector General Michael J. Missal
 Related Reports: 
VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2023Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as RequiredReview of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 PandemicRead the VA OIG's 90th Semiannual Report to Congress.

In this latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023.      
 
“Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome.” 
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
Related Report: 
Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas
Published: 6/28/2023
Report #22-02725-132

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023.
“Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” 
– Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
 
Related Report
Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri