Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Quality of Care Issues
 

VA Nebraska-Western Iowa
 

Health Care System
 

Omaha, Nebraska
 

And
 

VA Central Iowa Health Care System
 

Des Moines, Iowa
 

Report No. 11-02275-269 September 6, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations regarding the quality of care received 

by a patient at both the Omaha, Nebraska (system 1) and Des Moines, Iowa (system 2) 

VA Health Care Systems. The complainant alleged that: 

	 While at system 1 a patient: (1) suffered a stroke that was unnoticed by the 

Intensive Care Unit (ICU) nursing staff, (2) did not receive assistance with his 

meals and other activities of daily living (ADLs) while on the general medicine 

unit, (3) did not receive rehabilitative therapy, (4) did not receive a scheduled 

pulmonary therapy treatment, (5) did not receive pain medication in a timely 

manner, and (6) had a substantial delay in receiving prescribed seizure medication 

by mail. 

	 While at system 2 the same patient: (1) did not receive assistance with his ADLs, 

(2) did not receive speech therapy, and (3) was discharged abruptly without 

discharge planning. 

We substantiated the following allegations: 

	 The patient did not receive a scheduled pulmonary therapy treatment. 

	 There was a substantial delay in receiving seizure medication by mail. 

We determined that the patient was not reassessed for pain medication effectiveness 

according to policy. 

We recommended that the System 1 Director ensure that clinicians review the delay in 

this patient’s receipt of his non-formulary medications and take action as deemed 

necessary and ensure that pain assessments and reassessments are done according to 

policy. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, VA Midwest Health Care Network (10N23) 

SUBJECT:	 Healthcare Inspection–Quality of Care Issues Omaha, Nebraska and Des 

Moines, Iowa VA Health Care Systems 

Purpose 

At the request of Senator Charles Grassley, the VA Office of Inspector General (OIG) 

Office of Healthcare Inspections conducted an inspection to determine the validity of 

allegations regarding the quality of care received by a patient at both the Omaha, 

Nebraska (system 1) and Des Moines, Iowa (system 2) VA Health Care Systems. 

Background 

VA Omaha, Nebraska (system 1) is comprised of two campuses located in Grand Island 

and Omaha, Nebraska. System 1 is part of Veterans Integrated Service Network (VISN) 

23, serving an estimated total veteran population of 91,000 in 44 counties in Nebraska, 

western Iowa, Missouri, and parts of Kansas. System 1 provides a broad range of 

inpatient and outpatient health care services. Outpatient care is also provided at 

seven community based outpatient clinics (CBOCs) located in North Platte, Grand Island, 

Holdrege, Bellevue, Lincoln, and Norfolk, NE, and Shenandoah, IA. 

VA Des Moines, Iowa (system 2) is also part of VISN 23, serving a veteran population of 

over 100,000 from more than 42 counties in central Iowa and northern Missouri. System 

2 provides acute and specialized medical and surgical services, residential outpatient 

treatment, mental health, and long-term care services. In addition, system 2 operates 

five CBOCs located in Knoxville, Marshalltown, Mason City, Fort Dodge, and Carroll, 

IA. 

The complainant alleged that the patient received poor quality care while at both system1 

and system 2. Specifically, the complainant alleged that: 

	 While at system 1, the patient: (1) suffered a stroke that was unnoticed by the 

Intensive Care Unit (ICU) nursing staff, (2) did not receive assistance with his 

VA Office of Inspector General 1 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

meals and other activities of daily living1 (ADLs) while on the general medicine 

unit, (3) did not receive rehabilitative therapy, (4) did not receive a scheduled 

pulmonary therapy treatment, (5) did not receive pain medication in a timely 

manner, and (6) had a delay in receiving prescribed seizure medication by mail. 

	 While at system 2, the patient: (1) did not receive assistance with his ADLs, (2) 

did not receive speech therapy, and (3) was discharged abruptly without discharge 

planning. 

Scope and Methodology 

On May 10, 2011, we interviewed the complainant by telephone and we reviewed the 

patient’s electronic medical record (EMR). We conducted a site visit at system 1 on 

May 16–18 and at system 2 on May 18–19. We interviewed senior managers, service 

chiefs, physicians, medical residents, and other staff involved in the patient’s care. We 

also reviewed local policies and other related documents. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Case Summary 

The patient was a male in his sixties with a history of atrial fibrillation,2 left ventricular 

hypertrophy, hypertension, and chronic obstructive pulmonary disease. He was on longterm anticoagulation therapy3 for atrial fibrillation. 

The patient was first seen at the Shenandoah CBOC in June 2009. Documentation notes 

that he had an elevated prostate-specific antigen4 and was referred to the system 1 

urology clinic for treatment. He had a prostate biopsy in August, which was positive for 

prostate cancer. The urologist recommended surgical treatment after a pre-operative 

evaluation, and the patient was cleared for surgery. 

In December, the patient requested a radiation oncologist consultation. He was referred 

to nearby Creighton University Medical Center. The radiation oncologist reviewed the 

treatment options with the patient, and the patient chose radiation therapy instead of 

surgery. Radiation therapy treatments began in December 2009 and were completed in 

March 2010. The patient was followed in the system 1 primary care and urology clinics 

throughout this time and experienced no apparent complications. 

1 There are six basic ADLs: eating, bathing, dressing, toileting, transferring (walking), and continence.
 2 Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body.
 3 During anticoagulation therapy, medications “blood thinners” are administered to slow the rate in which a patient’s
 

blood clots.
 4 This is a protein produced by cells of the prostate gland.
 

VA Office of Inspector General 2 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

In mid-June, 2010, the patient presented to system 1’s Emergency Department with 

generalized complaints of not feeling well. The patient was diagnosed with 

hyponatremia (low sodium level) and hyperkalemia (high potassium level). He was 

advised to discontinue one of his medications and to follow up in 2–3 days with his 

primary care provider (PCP). The patient was planning to go out of town and would not 

be returning for 5 days. He was advised against traveling, and was given an appointment 

for the day of his return, with instructions to seek urgent care if his symptoms did not 

resolve or worsened while traveling. 

The patient returned to system 1’s Emergency Department six days later with pain and 

redness around the buttocks and scrotum with associated purulent drainage and fever. He 

was admitted to the medical unit with a diagnosis of gluteal abscess and cellulitis. He 

was placed on intravenous antibiotics and evaluated by infectious diseases, urology, and 

surgery consultants within 5 hours from the time of his admission. His anticoagulation 

therapy was discontinued upon admission because of the need for surgical debridement5 

of his wounds. 

The next day, the patient’s abscess was debrided, and he was found to have right gluteal 

and pre-sacral abscesses complicated by necrotizing fasciitis.6 Two days later, the patient 

underwent extensive surgical debridement of the perineum, right groin, right gluteal 

region, and scrotum. While in the post-operative recovery unit, he became hypoxic and 

unresponsive. He was intubated (mechanical ventilation) and transferred to the intensive 

care unit (ICU). He was monitored and examined with standard ICU protocols. On postoperative day (POD) 3, his respiratory status had stabilized, and he was removed from 

mechanical ventilation (extubated). An ICU nurse documented right-sided weakness, 

facial droop, and an inability to speak. Less than 3 hours after extubation, an ICU 

physician ordered further evaluation to include a head computerized tomography (CT) 

scan. The head CT scan showed a left parietal infarct.7 The ICU physician requested 

both cardiology and neurology consultations. The neurologist and cardiologist 

documented that they suspected the cause was an embolic stroke8 as opposed to a 

thrombolic stroke. The latter was believed to be less likely due to the inability to 

anticoagulate given this patient’s history of atrial fibrillation with anticoagulant therapy. 

Stroke treatments and therapies were initiated, which included physical and speech 

therapy with a swallowing assessment. 

5 Debridement is a surgical procedure used to cut away dead or contaminated tissue or foreign material from a
 

wound to prevent infection.

6 Necrotizing fasciitis is commonly known as ”flesh-eating disease or syndrome” is caused by bacteria, and can
 

destroy skin, fat, and tissues covering the muscles.

7 An infarct is an area of tissue death due to a local lack of oxygen caused by obstruction of the tissue's blood
 

supply.

8 An embolic stroke is caused by the blockage of an artery by an arterial embolus which is a traveling particle or
 

debris in the arterial bloodstream originating from elsewhere.
 

VA Office of Inspector General 3 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

The patient was transferred to a medical unit on POD 5, and his treatments for wound 

infections and post-stroke therapies continued. Anticoagulation therapy was resumed 2 

weeks after his stroke. 

The patient’s wounds showed progressive healing until mid-July when he developed 

more drainage from the pre-sacral area. The wound tested positive for both methicillinresistant Staphylococcus aureus9 and vancomycin-resistant enterococci10 organisms. A 

peri-rectal abscess was identified by a CT scan. 

On POD 24, the patient’s hospitalization was further complicated by a partial bowel 

obstruction. He was treated with conservative therapies with gradual resolution. He was 

also followed closely by the nutrition team, which ordered parenteral nutrition11 with 

gradual oral intake and diet modifications. 

On POD 28, the patient was discharged to system 2’s long-term care facility for 

continued antibiotics, wound care, and stroke therapies. At the time of discharge, his 

functional capacity assessments indicated that his speech was understandable, but he had 

residual mild to moderate dysarthria.12 His wounds were allowed to heal through gradual 

granulation tissue growth. He was discharged from system 2 in early September. Prior 

to discharge, his functional status was re-assessed, and adaptive home assistance devices 

were ordered. Home wound care and speech therapy were ordered prior to the patient’s 

discharge. 

Inspection Results 

Issue 1: Intensive Care Unit Monitoring 

We did not substantiate that the nurse caring for the patient during this time was unaware 

of changes in the patient’s condition. The patient did suffer a stroke while in the ICU at 

system 1 and this was recognized in a timely manner. 

Local policy13 states that patients in the ICU are to have vital signs14 monitored every 

2 hours. In addition, patients are to be reassessed by a registered nurse at least twice in 

an 8-hour shift or three times in a 12-hour shift, or when the patient’s status/condition 

changes. Our review of the patient’s EMR and the ICU flow sheet15 for the date in 

9 This is an infection caused by a strain of staphylococci bacteria that has become resistant to the antibiotics
 

commonly used to treat ordinary staphylococci infections.

10 Vancomycin-resistant enterococci is a bacteria strain of the genus Enterococcus that is resistant to the antibiotic
 

vancomycin.

11 Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion.
 12 Dysarthria is a motor speech disorder caused by impairment of the muscles used in speech.
 13 Nebraska-Western Iowa HCS, Policy PCS-114, Acute Care: Assessment of Patients, April 30, 2010.
 14 Vital signs are measures of various physiological statistics, taken to assess the most basic body functions.
 15 An ICU flow sheet is a graphic summary of several changing factors, especially the patient's vital signs and any
 

treatments and medications given during a 24-hour period.
 

VA Office of Inspector General 4 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

question revealed that a nursing reassessment, including vital signs, was done according 

to policy. Our interview with the nurse revealed that during the last reassessment, just 

prior to the wife’s visit, there were no significant changes in the patient’s condition. 

Issue 2: Activities of Daily Living 

We could not substantiate or refute that the patient did not receive assistance with his 

ADLs, on several occasions, as reported by the complainant at both system1 and system 

2. 

According to the complainant, the patient was not given assistance with feeding on 

several occasions at both systems. On one occasion at system 1, while the patient 

received assistance getting up to a chair, it was observed that he needed to be cleaned. 

Allegedly, the nurse said she would return to clean him up; however, she did not return. 

A subsequent request was made to clean the patient. The nurse stated she would come in 

15 minutes; however, the nurse returned only to drop off linen and did not clean the 

patient. When the wound care doctors came to examine the patient, they were asked, 

“how long would it take the patient’s open wound to get infected from sitting in his own 

[feces]?” 

We interviewed nurses at both systems and reviewed the patient’s medical record and 

could not find any evidence to support or refute this allegation. 

Issue 3: Rehabilitative Services 

We did not substantiate that the patient did not receive rehabilitation services following 

his stroke. The patient’s EMR notes that the patient received speech, occupational, and 

physical therapy treatments at system 1. The patient also received speech therapy at 

system 2. The patient was discharged home from system 2 with four fee basis speech 

therapy scheduled sessions. We reviewed documentation of the four sessions from the 

approved fee basis provider who is located near the patient’s home. 

Issue 4: Pulmonary Therapy Treatments 

We substantiated that the patient did not receive at least one of his scheduled pulmonary 

therapy treatments at system 1. The treatment order was written for four times a day. 

Four times a day at system 1 is: 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. According 

to the complainant, the therapist entered the room while the doctors were examining the 

patient and said they would return later but never did. Documentation in the EMR 

verifies that the therapist administered a total of two treatments on July 5: one treatment 

at 5:26 p.m. and another at 8:43 p.m. Taking into consideration the time the order was 

written (12:44 p.m.), time for staff to review, transcribe, and notify the therapists; the 

patient could reasonably have expected to receive three treatments that day. 

VA Office of Inspector General 5 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Issue 5: Pain Medication 

We could neither substantiate nor refute the allegation that the patient did not receive 

pain medication in a timely manner when requested at system 1. 

On one particular occasion, the nurse allegedly was asked several times to give the 

patient something for pain. Reportedly, the nurse became annoyed with the continued 

requests. The nurse administered the pain medication later; however, during our 

inspection, we could not determine the time difference. 

Our review of the patient’s EMR confirms that the patient was assessed for pain and 

given pain medication at 5:00 p.m. on the date in question. Local policy16 states that 

post-intervention documentation for pain medication’s effectiveness will be documented 

prior to the end of the staff’s tour of duty. We found no documentation in the patient’s 

EMR of a reassessment for pain medication effectiveness. 

Issue 6: Discharge Planning 

We did not substantiate that the patient did not receive discharge planning in accordance 

with system 2’s policy. Allegedly, the facility provided the patient’s family no prior 

notification regarding his discharge other than a telephone call during the morning of 

September 9, when the facility informed the family the patient was ready to be picked up. 

Local policy17 states that a patient and/or significant other(s) shall have an active 

involvement in developing his/her discharge plan. Documentation in the EMR shows 

that on several occasions prior to discharge, the patient and his wife were involved in 

discharge planning discussions. Our interview with the discharge planning nurse 

revealed that the patient went home on a weekend pass just prior to discharge as a trial to 

better assess his discharge needs. We found that the patient’s discharge process was 

managed according to policy including documented family involvement. 

Issue 7: Mail Order Medication 

We substantiated that the patient did not receive prescribed mail order medication within 

the timeframe indicated by the prescribing physician. Further action should have been 

taken to ensure that the patient’s prescription was filled and mailed as ordered. In 

addition, the patient reportedly did not receive a temporary medication supply to take 

during the interim. This was confirmed by the prescribing physician. 

A timeline of encounters from the time the patient first presented to the Shenandoah 

CBOC PCP on September 14 until receiving his prescribed medication by mail on 

November 10 is displayed in the Table below. 

16 VA Nebraska-Western Iowa Health Care System, Policy PCS-020, Pain Assessment and Management,
 

October 18, 2009.

17 VA Central Iowa Health Care System, Patient Care Program-6, Discharge Planning Policy, September 1, 2008.
 

VA Office of Inspector General 6 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Table. Timeline of Encounters from first Patient Shenandoah CBOC PCP Visit to 

Receiving Medication by Mail. 

Day # Date Electronic Medical Record Documentation 

1 September 14 Patient seen by the PCP for seizures and a neurology consult was 

submitted. 

3 September 16 Neurology physician contacted patient by telephone to discuss plan of care. 

14 September 27 Patient seen in the neurology clinic and seizure medication was ordered. A 

non-formulary consult was not completed. 

15 September 28 Medication order was placed on hold by pharmacy. View Alerts18 were sent 

by the pharmacist to the neurology physician. 

36 October 19 Patient suffered another seizure at home while waiting for medication to 

arrive by mail. Patient was seen by the CBOC PCP. 

37 October 20 View Alerts were acknowledged by the neurology physician, and a nonformulary consult was completed. 

38 October 21 Pharmacy filled the mail order prescription. Wife returned to system 1 to 

pick up the medication, however, she was told the medicine had been 

mailed. 

51 November 04 Wife returned again to system 1 and received a temporary supply of 

medication while still awaiting medication by mail. 

57 November 10 Patient received the seizure medication by mail. 

Conclusions 

We found that the patient had suffered a stroke while in the ICU at system 1. However, 

we did not substantiate that the nursing staff were unaware of changes in the patient’s 

condition. We determined that the patient did not receive one scheduled pulmonary 

therapy treatment on the day in question. We substantiated that there was a substantial 

delay in the patient receiving his medication by mail. 

We did not substantiate that the patient: (1) did not receive assistance with his ADLs at 

both systems, (2) did not receive rehabilitative therapy at both systems, (3) did not 

receive pain medication in a timely manner at system 1, and (4) was discharged from 

system 2 abruptly without discharge planning. 

We determined that the patient was not reassessed for pain medication effectiveness. 

18 View Alerts are computer system warnings used by the pharmacy to flag orders, alerting the physician that the 

order is incomplete. 

VA Office of Inspector General 7 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Recommendations 

Recommendation 1. We recommended that the System 1 Director ensure that clinicians 

review the delay in this patient’s receipt of his non-formulary medications and take action 

as deemed necessary. 

Recommendation 2. We recommended that the System 1 Director ensure that pain 

assessments and reassessments are completed according to policy. 

Comments 

The VISN and Facility Directors agreed with the findings and recommendations (see 

Appendixes A and B, pages 10–14, for the full text of their comments). The 

implementation plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 8 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 12, 2011 

From: Director, VA Midwest Health Care Network (10N23) 

Subject: Healthcare Inspection–Quality of Care Issues Omaha, Nebraska 

and Des Moines, Iowa VA Health Care Issues 

To: Director, Chicago Office of Healthcare Inspections (54CH) 

Thru: Director, Management Review Services (10A4A4) 

We concur with the action plans regarding the 

recommendations identified in this report. 

Janet P. Murphy, MBA 

VA Office of Inspector General 9 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Appendix B 

System 1 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 12, 2011 

From:	 Acting Director, VA Nebraska-Western Iowa Health Care 

System (Omaha Division) (636/00) 

Subject:	 Healthcare Inspection–Quality of Care Issues Omaha, Nebraska 

and Des Moines, Iowa VA Health Care Systems 

To:	 Director, VA Midwest Health Care Network (10N23) 

This is to acknowledge the receipt and review of the findings 

and recommendations of the Office of Inspector General 

Healthcare Inspection. Nebraska-Western Iowa Health Care 

System concurs with the findings and recommendations. 

Corrective action plans have been developed or implemented 

for the recommendations. 

Our appreciation is extended to the OIG Healthcare 

Inspection team. We appreciate the thorough review and the 

opportunity to further improve the quality of care we provide 

to our Veterans. 

Nancy A. Gregory, FACHE 

VA Office of Inspector General 10 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Appendix B 

System 2 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 August 3, 2011 

From:	 Director, Des Moines VA Health Care System (636A6/00) 

Subject:	 Healthcare Inspection–Quality of Care Issues Omaha, Nebraska 

and Des Moines, Iowa VA Health Care Systems 

To:	 Director, VA Midwest Health Care Network (10N23) 

VA Central Iowa Health Care System (VACIHCS) 

appreciates the opportunity to have provisions of care to 

Veterans served by the system critically reviewed by the VA 

Office of Inspector General. 

I concur with the findings of the Draft Report pertaining to 

the quality of care provided at VACIHCS. There are no 

recommendations requiring corrective action by VACIHCS. 

Donald C. Cooper
 

Director, Des Moines VA Health Care System (636A6/00)
 

VA Office of Inspector General 11 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

System 1 Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the System 1 Director ensure 

that clinicians review the delay in this patient’s receipt of his non-formulary 

medications and take action as deemed necessary. 

Concur Target Completion Date: October 31, 2011 

Nebraska Western Iowa HCS concurs that clinicians review the delay in 

this patient’s receipt of his non-formulary medications and take action as 

deemed necessary. After reviewing the record it was noted on October 21, 

2010 the patient did pick-up his medications in person and on November 4, 

2010 he also received a week’s supply of medications prior to his 

medications arriving by mail. To prevent a delay in delivery of nonformulary medications, pharmacy will meet with key stakeholders to 

review the process. Stakeholders will include residents, representatives 

from medicine, surgery, mental health service lines, and off-site 

representatives. This group will 1) identify key process indicators to 

monitor on a real-time basis, 2) identify any barriers to the process and 

develop action plans to eliminate the barriers, 3) develop action plans to 

ensure sustainability of the process. Oversight of the non-formulary 

process including the key process indicators will be done in the 

Pharmacy/Therapeutic Committee meetings. Pharmacy will be working 

with the ACOS for Graduate Medical Education to further develop and 

refine the on-going resident education. Pharmacy will be meeting with the 

service chiefs to work collaboratively to 1) develop an education plan for 

attending physicians on the non-formulary process, and 2) develop a system 

for notification of concerns relating to the key process indicators. 

Status: In progress 

Recommendation 2. We recommended that the System 1 Director ensure 

that pain assessments and reassessments are completed according to policy. 

Concur Target Completion Date: October 31, 2011 

VA Office of Inspector General 12 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Nebraska Western Iowa HCS concurs that pain assessments and 

reassessments should be completed according to policy. In May, an 

inpatient committee, consisting of representatives from the inpatient 

medical-surgical units, was formed to discuss pain data per unit, develop 

pain education for nursing staff, and review data. Members of this 

committee also serve as nurse champions. These champions will serve as a 

resource for the inpatient nursing staff and assist with monitoring of prn 

effectiveness on their unit. The Pain Policy is undergoing review with an 

anticipated concurrence data of recommended changes by September. 

Changes to the nursing staff’s daily use of the prn effectiveness worksheet 

have been implemented. Work with the Data Analyst Team is being done 

to create an electronic automatic report to monitor for prn effectiveness. 

Pain policy/procedure education was completed at the annual nursing 

Education Fair. This education is also provided to new nursing staff during 

nursing orientation. Pain competency was assessed during this year’s 

annual nursing competency evaluations. 

Status: In progress 

VA Office of Inspector General 13 
Quality of Care Issues Omaha, Nebraska and Des Moines, Iowa VA Health Care Systems 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Wachita Haywood, RN, Project Leader 

Verena Briley-Hudson, ARNP, MN 

JoDean Marquez, RN 

Monika Gottlieb, MD 

Judy Brown, Program Support Assistant 

VA Office of Inspector General 14 
Quality of Care Issues Omaha and Des Moines, Iowa VA Health Care Systems 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, VA Nebraska-Western Iowa Health Care System (636/00) 

Director, VA Central Iowa Health Care System (636A6/00) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senators: Charles Grassley, Tom Harkin, Mike Johanns, and Ben Nelson

U.S. House of Representatives: Jeff Fortenberry, Lee Terry, Adrian Smith, 

Bruce L. Braley, David Loebsack, Leonard Boswell, Tom Latham, and Steve King 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 15