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VA OIG Finds Pattern of Deficiencies


Last updated 5/19/2020 at 10:20pm

The Office of the Inspector General for the Department of Veterans Affairs has been busy following up on allegations and conducting inspections and investigations.

The OIG was asked to investigate deficient staffing and competencies in sterile processing at one of the VA’s health care facilities. The end result: For six years the facility hadn’t followed manufacturer instructions for sterilization. Specifically, medical staff reassembled gadgets before sterilizing. No patients were harmed, the OIG determined. But that same facility failed to follow guidelines for having a certain level of staff in the assistant chief position.

At another facility, the OIG’s inspection determined that the cardiac care of five patients was deficient. Specifically, a cardiologist didn’t follow up with a patient and didn’t tell the patient’s doctor about the results. The patient died. In another assessment a cardiologist failed to provide follow-up care and did not correctly read electrocardiograms for four patients.

Another facility was found deficient in mental health care. A homeless veteran received 90 days of in-house mental health care, at which time he was released. The psychiatrist requested an extension of care beyond that 90 days. The request was denied because the patient had Medicaid and the VA could transfer his care elsewhere. The VISN Chief Medical Officer was not notified (as is required).

The physical and IT infrastructure upgrades at one VA facility were found to be deficient. The telecommunications rooms were not going to be completed until four months after the scheduled start date. Some 31% of end user devices hadn’t been upgraded. And authorization from the DOD to connect to the new health record system hadn’t been received. The OIG’s opinion: The VA committed to the start date without asking the facility about the status of the center. A year before that, the VA had announced a start date without assessing facility infrastructures.

Did you notice the pattern in the cases above? The word for the day: deficient.

(c) 2020 King Features Synd., Inc.


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