Healthcare Facility Inspection of the VA Loma Linda Healthcare System in California

Report Information

Issue Date
Report Number
25-00208-64
VISN
22
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
8
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 VA Loma Linda Healthcare System in California. 

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

The OIG issued eight recommendations for VA to correct identified deficiencies in two domains:
   1.    Environment of care
     •    Community living center dementia unit shower room safety
     •    Emergency Department patient privacy assessment
     •    Eyewash station cleanliness and function
   2.    Patient safety
     •    Test result communication policy
     •    Service-level workflows
     •    VHA policy change processes
     •    Test result communication performance metrics
     •    Quality and Patient Safety Council meeting attendance

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2026

Facility leaders ensure the community living center’s dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2026

The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2026

Facility leaders ensure all eyewash stations are clean and function properly.

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

The Medical Center Director ensures the facility has a written policy for communication of test results.

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

The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.

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

The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.

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

The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.