OIG reviewed allegations that census in the Emergency Department (ED) at the Memphis VA Medical Center, Memphis, TN exceeds bed capacity on a regular basis, compromising patient safety; that ED equipment and supplies were inadequate; and that management was unresponsive to these concerns. We substantiated that there were significant delays in the ED, but did not find that patients experienced negative outcomes as a result of excessive ED length of stay (LOS). We found that the facility’s sustained performance for ED LOS is far below the VHA standard. With the exception of availability of ultrasound services, we found that ED resources were adequate. We found that Emergency Department Integrated Software, and VistA data related to ED LOS times were unreliable. We substantiated that management was aware of these issues but had not taken adequate action for resolution. We recommended that the Facility Director ensure that actions are taken to reduce ED LOS, increase the availability of ultrasound services for ED patients, and improve the accuracy of ED flow data. The Veterans Integrated Service Network and Facility Directors agreed with the findings and recommendations and provided an acceptable action plan.