Healthcare Inspection – Cardiothoracic Surgery Program and Cardiac Catheterization Laboratory Concerns, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma

At the request of former Senator Tom Coburn and an anonymous complainant, OIG conducted reviews to evaluate the alleged closure of the Cardiothoracic (CT) Surgery program and assess Cardiac Catheterization Laboratory (CCL) medication administration and Omnicell® medication dispensing system access issues at the Oklahoma City VA Health Care System (facility), Oklahoma City, OK. We did not substantiate that the facility closed the CT surgery program. Rather, facility leadership paused CT surgeries in order to evaluate the program following patient deaths. We did not substantiate the allegation that CCL nurses administered medications to patients in the CCL without a physician’s order or that the two patients we reviewed suffered harm related to CCL medication administration practices. We could not substantiate that a nurse manager had staff passwords to the Omnicell® and could use the passwords to access and remove medications under another nurse’s account. Former Senator Coburn also requested OIG “conduct a thorough investigation of the care and management” of multiple areas of the facility; however, specific allegations or concerns were not provided. In response to this request and additional requests from Senator James Inhofe, we are continuing work to evaluate the facility’s quality management program, analyze data from VA’s Strategic Analytics for Improvement and Learning (SAIL) Value Model report, and follow up on the results of an Employee Assessment Review (EAR) survey. Our results from these reviews will be addressed in a future OIG report. We made no recommendations.