Report Summary

Title: Healthcare Inspection—Environment of Care and Other Quality Concerns, Cincinnati VA Medical Center, Cincinnati, Ohio
Report Number: 16-02094-219 Download
Issue Date: 5/3/2017
City/State: Cincinnati, OH
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

OIG conducted an inspection at the request of Senator Sherrod Brown to assess allegations concerning the environment of care, emergency airway management (EAM) of patients, and clinical practice by a former Acting Chief of Staff at the Cincinnati VA Medical Center (facility), Cincinnati, OH. We were asked to determine whether: Clean and dirty materials were stored together in the same location after an OIG 2015 recommendation to store clean and dirty materials separately; Reduced availability of EAM providers may have led to a “close call” [delayed intubation of a patient]; Deficiencies regarding the former Acting Chief of Staff’s professional clinical practice had been identified by the facility during peer reviews or Ongoing Professional Practice Evaluations. We substantiated that clean and dirty patient care equipment items were stored together in the Community Living Center following closure of an OIG recommendation made during a review of the facility in October 2014 (CAP Review of the Cincinnati VA Medical Center, Cincinnati, Ohio, Report No. 14-04215-99, February 4, 2015). We did not substantiate a reduction in availability of facility providers for EAM or a delay in the intubation of a patient. We did not substantiate reported deficiencies in the clinical practice of the former Acting Chief of Staff. We recommended that the facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.