Veteran Oversight Now

Latest Episodes:

Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center—Rebroadcast Oct 17, 2024

Show notes

In this latest episode of Veteran Oversight Now, we’re revisiting a highly downloaded episode from April 2024—Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center.

Hear from a VA OIG healthcare inspection hotline director discuss how 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 August 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

Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning Aug 21, 2024

Show notes

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used during subsequent procedures were, in fact, not cleaned per requirements. The VA OIG also found that high-level disinfection documentation was missing and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024.

“If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas Jul 18, 2024

Show notes

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.

“If you go by the timeline, this is 17 days after the patient’s first visit to the emergency room with the shortness of breath problems. . . . Unfortunately, the patient completed suicide that same day without receiving the medication.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

This podcast edition also includes highlights of the VA OIG’s work from June 2024.

Patients Delayed Care Due to Failure to Follow Behavior Health Consult and Scheduling Process Jun 20, 2024

Show notes

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that some patients’ behavioral health consults were being discontinued at the Oklahoma City VA Medical Center, which resulted in some significant delays in patients receiving recommended behavioral health services. This podcast edition also includes highlights of the VA OIG’s work from May 2024.

“Both in the allegation and what we found was basically that the program manager lacked a working knowledge of the consult management and scheduling processes.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

IG Missal Highlights 91st Semiannual Report to Congress May 29, 2024

Show notes

In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered our oversight work from October 1, 2023, to March 31, 2024. Specifically, he shares results of our most recent work related to VA’s Electronic Health Record Modernization program. To date, the VA OIG has published 19 products addressing the program’s implementation across VA facilities nationwide. In addition, IG Missal shares his thoughts on the VA OIG’s work related to VA’s personnel suitability program as well as recent crime and fraud alerts. A recent fraud alert encourages VBA staff to report when veterans share that they are being charged high fees from unaccredited individuals for assistance with completing disability benefits questionnaires (DBQs) or an initial claim filing. This podcast edition also includes highlights of the VA OIG’s work from April 2024.

“It's wonderful to be able to talk about all the incredible work that our staff performs in the service of our nation's veterans. I could not be more proud of the progress our staff has made in achieving our mission to serve veterans and the public by conducting meaningful, fair, and evidence-driven oversight of VA.” – Inspector General Michael J. Missal.

Related Report: 91st Semiannual Report to Congress

Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center Apr 26, 2024

Show notes

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

Chronic Leadership Failures Plague Cardiology Department at Indiana VAMC Mar 28, 2024

Show notes

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

Unpaid Postage Bill Delays Critical Cancer Screenings Feb 22, 2024

Show notes

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

IG Missal Reflects on Inspector General 45th Anniversary and Latest Semiannual Report to Congress Nov 28, 2023

Show notes

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:

Read the VA OIG's 90th Semiannual Report to Congress.

Lessons Learned after Patient Death following a Fall in a Las Vegas VA Outpatient Clinic Sep 26, 2023

Show notes

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

Published: 6/28/2023

Report #22-02725-132

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