OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Environment of Care Deficiencies in the Operating Room, VA Connecticut Healthcare System, West Haven, Connecticut
Report Number: 13-03747-76 Download
Issue Date: 2/18/2014
City/State: West Haven, CT
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted an inspection in response to allegations about deficiencies in the environment of care in the operating room (OR) at the VA Connecticut Healthcare System (facility), West Haven, CT. We found that cleanliness of the OR could not be assured due to inadequate staff resources, incomplete and inconsistent procedures, poor supervision and training of Environmental Management Services (EMS) staff, and lack of oversight. We also found that safeguards were inadequate for ensuring patient and employee safety when infectious patients requiring special precautions were scheduled for OR procedures concurrently with noninfectious patients. We also identified issues related to maintenance of the Heating, Ventilation, and Air Conditioning system and insect control in the OR. Although our findings substantiated an increased risk to patients and staff, we found no conclusive evidence that the environment of care deficiencies in the OR resulted in negative patient outcomes.

We recommended that the Facility Director strengthen procedures for OR cleaning and develop and implement policies and procedures to address management of infectious patients, the Heating, Ventilation, and Air Conditioning system preventive maintenance, and insect control in the OR. We also recommended that the Facility Director reassess EMS staffing needs in the OR, assign personnel requisite to the workload, and ensure that EMS staff and supervisors receive training on OR environment of care requirements. Additionally, we recommended that the Facility Director implement procedures to monitor the OR environment of care and to address identified deficiencies.