Healthcare Facility Inspection of the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington

Report Information

Issue Date
Report Number
24-00599-202
VISN
20
State
Idaho
Oregon
Washington
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Safety
Supplies and Equipment
Major Management Challenges
Healthcare Services
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued nine recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Signs and maps
     •    Emergency generator and fire door inspection and testing
     •    Environment of care committee meetings
     •    Mental Health Residential Rehabilitation Treatment Program area cleanliness
     •    Hands-free sanitizer dispensers
     •    Guidance for shelter-in-place supplies
   2.    Patient safety
     •    Service-level workflows for the communication of test results
     •    Process to monitor the communication of test results
     •    Improvement actions from root cause analyses

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2025

The Medical Center Director ensures an environment of care committee meets, as required.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2025

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.