Leaders Did Not Adequately Review and Address a Dental Hygienist’s Quality of Care at the VA Southern Nevada Healthcare System in Las Vegas

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to analyze facility leaders’ response to allegations that a dental hygienist failed to follow Veterans Health Administration and facility policies and provide quality care. The OIG determined that supervisors did not ensure the correction of patient safety concerns related to the dental hygienist’s practice after having knowledge of the repeated concerns for approximately two years. 

A supervisor requested a factfinding, which substantiated the dental hygienist falsified a patient’s electronic health record; however, the falsification went unaddressed. The factfinding was not completed timely and, although requested, a review of two medication storage violations was not included. Additionally, a supervisor considered but did not implement a performance improvement plan to address repeated clinical practice concerns and infection control violations. 

Due to conflicting recollections, the OIG was unable to determine whether a supervisor recommended a comprehensive review of the dental hygienist’s care to the credentialing and privileging manager, which is a step in the state licensing board (SLB) reporting process. Also, on the provider exit review form, a supervisor did not accurately reflect clinical care concerns regarding the dental hygienist. An accurate form would have prompted initiation of the SLB reporting process. Further, supervisors did not ensure that patient safety reports were submitted through the Joint Patient Safety Reporting system as required. 

The OIG determined that the Chief of Staff (COS) did not consider a management review of the dental hygienist’s care after receiving a recommendation from a risk manager to conduct a management review. The COS also did not effectively utilize high reliability organization principles to become aware of the full extent of patient safety concerns regarding the dental hygienist. 

The OIG made eight recommendations to the Facility Director.