Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID 19. The OIG did not substantiate that Emergency Department staff failed to notify Imaging Department staff that a patient was suspected to have COVID-19 before sending the patient to the Imaging Department. At the time of the patient’s transport to the Imaging Department, Emergency Department staff had not identified suspicion of COVID-19. However, Emergency Department staff failed to alert Imaging Department staff of the patient’s potential influenza. The OIG did not substantiate that Imaging Department supervisors failed to properly and promptly notify Imaging Department staff who had contact with a patient who was diagnosed with COVID-19 after admission to the facility, or that leaders failed to take appropriate action following staff exposure to a patient with COVID-19. The OIG identified some missteps in the facility’s processes when responding to staff exposure, which affected the accuracy of exposure risk assessments and monitoring for some exposed staff. While missteps were noted, the facility made a significant and timely effort to identify staff with potential exposure and respond in accordance with the most current guidance from the Centers for Disease Control and Prevention and Oregon Health Authority. Facility leaders and Infection Prevention and Control staff developed and revised COVID-19-related policies as new guidance became available. The OIG made five recommendations to the Facility Director related to communicating infection control precautions prior to transfer, management of staff with exposure to high-consequence infections, and inclusion of a detailed staff exposure management process in relevant facility policies.