Review of the Inpatient Mental Health Unit Environment of Care, Staffing, and Administrative Processes at the VA Nebraska-Western Iowa Health Care System in Omaha

Report Information

Issue Date
Report Number
25-00421-37
VISN
23
State
Nebraska
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Mental Health
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
Yes

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection of the VA Nebraska-Western Iowa Health Care System (facility) in Omaha from November 2024 through May 2025, following a congressional request to evaluate allegations related to the inpatient mental health unit’s environment of care. The OIG also evaluated allegations from another complainant regarding unit staffing and identified additional concerns related to training, policy guidance, and oversight.

The OIG substantiated facility leaders did not ensure adequate night lighting in patient rooms, which may affect patients’ sleep and hinder staff’s ability to conduct safety rounds. The OIG also substantiated the unit was not consistently staffed with the required number of employees trained in therapeutic containment for high-risk areas, placing patients and employees at risk. Although the OIG did not substantiate allegations that the unit was unclean and restroom doors did not lock, the OIG found female patients were unable to access the restroom without staff assistance.

The OIG found nursing leaders did not (1) develop a required patient safety rounding standard operating procedure, increasing the risk of inconsistent observation practices, and (2) ensure a clear process for using a risk for violence assessment, contributing to the inability to determine required staffing.

Additionally, facility leaders did not (1) consistently report root cause analysis action items, which may result in leaders being unaware of opportunities to improve care, and (2) notify Veterans Integrated Service Network (VISN) 23 leaders of bed closures exceeding 60 days, misrepresenting available bed capacity.

The Under Secretary for Health concurred with 2 OIG recommendations related to high-risk workplace staffing guidance; the VISN Director concurred with 1 recommendation regarding oversight of bed changes; and the Facility Director concurred with 10 recommendations regarding unit lighting, rounding procedures, mitigation planning, staffing and training requirements, and root cause analysis reporting.

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 VA Nebraska—Western Iowa Health Care System Director ensures the installation of night lighting changes to accommodate patient comfort and facility staff’s ability to safely conduct rounding in applicable inpatient mental health unit patient rooms.

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

The VA Nebraska—Western Iowa Health Care System Director ensures establishment and implementation of guidance related to the facility inpatient mental health unit staff’s use and security of handheld flashlights to ensure appropriate education and training of handheld flashlights usage and storage.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Nebraska—Western Iowa Health Care System Director establishes and ensures implementation of a patient safety observation rounds standard operating procedure consistent with Veterans Health Administration requirements.

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

The VA Nebraska—Western Iowa Health Care System Director reviews facility Mental Health Environment of Care Checklist processes related to development of mitigation plans as required by the Veterans Health Administration, and monitors compliance.

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

The VA Nebraska—Western Iowa Health Care System Director ensures compliance with Veterans Health Administration staffing requirements for areas identified as high-risk, such as the inpatient mental health unit, and monitors compliance.

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

The Under Secretary for Health evaluates the Veterans Health Administration written guidance for high-risk workplace staffing and determines if clarification is needed.

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

The VA Nebraska—Western Iowa Health Care System Director ensures staff that may provide coverage on the inpatient mental health unit receive applicable Prevention and Management of Disruptive Behavior training for high-risk units.

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

The VA Nebraska—Western Iowa Health Care System Director strengthens processes to ensure that supervisors are made aware of staff members that have not completed the applicable Prevention and Management of Disruptive Behavior training for high-risk units, to include the hands-on component, and monitors compliance.

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

The Under Secretary for Health considers written guidance regarding risk for violence assessment use in units identified as a high-risk workplace that can be used to temporarily change a unit’s acuity level and staffing needs.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Nebraska—Western Iowa Health Care System Director reviews and ensures consistent application of facility nursing leaders’ use of risk for violence assessment on the inpatient mental health unit, and monitors for compliance.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Nebraska—Western Iowa Health Care System Director evaluates the root cause analysis processes regarding reporting of action items and outcome measures in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Nebraska—Western Iowa Health Care System Director evaluates processes requesting and reporting changes to authorized and operating beds on the inpatient mental health unit, takes action as needed, and monitors compliance.

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Midwest Health Care Network Director strengthens processes to ensure adequate oversight and adherence to Veterans Health Administration requirements pertaining to changes to authorized and operating inpatient mental health unit beds.