Was she the victim of foul play, an accident, or did she choose to disappear? In this episode of The Vanished, we retrace Diana’s last known movements, strange witness accounts, and the lingering mystery that has never been solved or.. was never meant to be solved.
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Contenido proporcionado por VA Office of Inspector General and VA OIG. Todo el contenido del podcast, incluidos episodios, gráficos y descripciones de podcast, lo carga y proporciona directamente VA Office of Inspector General and VA OIG o su socio de plataforma de podcast. Si cree que alguien está utilizando su trabajo protegido por derechos de autor sin su permiso, puede seguir el proceso descrito aquí https://es.player.fm/legal.
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Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas
Manage episode 429500471 series 3333001
Contenido proporcionado por VA Office of Inspector General and VA OIG. Todo el contenido del podcast, incluidos episodios, gráficos y descripciones de podcast, lo carga y proporciona directamente VA Office of Inspector General and VA OIG o su socio de plataforma de podcast. Si cree que alguien está utilizando su trabajo protegido por derechos de autor sin su permiso, puede seguir el proceso descrito aquí https://es.player.fm/legal.
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.
Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas
29 episodios
CompartirManage episode 429500471 series 3333001
Contenido proporcionado por VA Office of Inspector General and VA OIG. Todo el contenido del podcast, incluidos episodios, gráficos y descripciones de podcast, lo carga y proporciona directamente VA Office of Inspector General and VA OIG o su socio de plataforma de podcast. Si cree que alguien está utilizando su trabajo protegido por derechos de autor sin su permiso, puede seguir el proceso descrito aquí https://es.player.fm/legal.
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.
Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas
29 episodios
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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 oversight work from April 1 to September 30, 2024. This edition also includes highlights of the VA OIG’s work from October 2024. “I’m extremely proud of all the enhancements we’ve made and the exceptional improvements we helped to bring about for VA’s programs and operations, which ultimately improve the lives of veterans and their family members.” – VA Inspector General Michael J. Missal…
In this latest episode of Veteran Oversight Now , we’re revisiting a highly downloaded episode from February 2024— Unpaid Postage Bill Delays Critical Cancer Screenings . Hear from a VA OIG healthcare inspection hotline director, who 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 September 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…
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 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…
1 Poor Paperwork Potentially Puts Patients at Risk: New Mexico VAMC Reuses Medical Devices without Documenting Proper Cleaning 22:36
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 Related Report: Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico…
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. Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas…
1 Patients Delayed Care Due to Failure to Follow Behavior Health Consult and Scheduling Process 23:15
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 Related Report: Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma…
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: 91s t Semiannual Report to Congress…
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…
1 IG Missal Reflects on Inspector General 45th Anniversary and Latest Semiannual Report to Congress 36:21
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 2023 Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as Required Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 Pandemic Read 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…
1 Veteran Suicide at Outpatient Clinic in South Carolina Highlights Tragic Missteps in Patient Care 47:21
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023. “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia…
1 Oversight, Employee Participation Critical to Patient Safety Programs Says Healthcare Hotline Director 38:50
In the latest episode of Veteran Oversight Now , a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023. “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare Inspections Related Publications: Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama (September 2, 2020) Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama (September 27, 2019)…
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