2008 The VA Office of
Inspector General,...conducted an
inspection at the VA Southern Nevada
Healthcare System in Las Vegas, NV, at
the request of Congressman Bob Filner,
Chairman of the House Committee on
Veterans’ Affairs...
determine...allegations made by
anonymous complainants...We
substantiated that refurbished scopes
were purchased and a scope broke...
GI providers reused
syringes...contaminated medication from
vials...contracts were awarded to the GI
provider group or that senior managers
received kickbacks. ...recommended
that a process be established to assure
adequate inspection, maintenance, and
replacement of patient care equipment.
Department of Veterans
Affairs
Office of Inspector
General Healthcare Inspection
Gastroenterology Service Issues at the
VA Southern Nevada Healthcare System
Las Vegas, Nevada
Report No. 08-01711-31
December 2, 2008
VA Office of Inspector General
Washington, DC 20420
To Report Suspected
Wrongdoing in VA Programs and Operations
Call the OIG Hotline – (800) 488-8244
Gastroenterology Service Issues at the
VA Southern Nevada Healthcare System,
Las Vegas, Nevada
Executive Summary
The VA Office of Inspector General,
Office of Healthcare Inspections
conducted an inspection at the VA
Southern Nevada Healthcare System in Las
Vegas, NV, at the request of Congressman
Bob Filner, Chairman of the House
Committee on Veterans’ Affairs. The
review was done to determine the
validity of a number of allegations made
by anonymous complainants regarding the
system’s gastroenterology (GI) services.
We substantiated that
refurbished scopes were purchased and a
scope broke during a GI procedure.
However, we did not substantiate that:
(a) the system had a high GI mortality
rate, (b) nurses experienced retaliation
for reporting substandard practices, (c)
a GI provider was permitted to forgo
documentation in VA patients’ medical
records, (d) GI providers reused
syringes or exposed veterans to
contaminated medication from vials while
contractors of the system or (e)
lucrative contracts were awarded to the
GI provider group or that senior
managers received kickbacks. We were
unable either to substantiate or refute
that GI equipment was improperly
sterilized.
We recommended that a
process be established to assure
adequate inspection, maintenance, and
replacement of patient care equipment.
We recommended that controls be
established to monitor and track all
VA-owned equipment that is repaired by
community vendors. We also recommended
that when an employee recognizes
Government property loss or damage, the
employee promptly notifies the
supervisor, who then notifies VA police.
Additionally, we identified that VA
acquisition regulations were not
followed after the contract with the GI
provider group expired in 2006.
We made three
recommendations to ensure that the
system takes actions to comply with the
regulations pertaining to services
provided by non-VA entities. The VISN
and System Directors agreed with our
findings and recommendations and
submitted appropriate action plans. We
will follow up on the planned actions
until they are completed.
Full Report (PDF)
