Healthcare Facility Inspection of the VA Washington DC Healthcare System

Report Information

Issue Date
Report Number
24-00551-64
VISN
5
State
District of Columbia
Maryland
Virginia
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
4
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 Washington DC Healthcare System. 

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

The OIG issued four recommendations for improvement in two domains:
 1.    Environment of care
   •    Crosswalk visibility and pedestrian safety
   •    Blanket warmer temperature
   •    Electrical issue
 2.    Patient safety
   •    Identifying adverse events that warrant institutional disclosures

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)

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.

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

The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2025

The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.

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

The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.