Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Follow-Up Evaluation of the 

W.G. (Bill) Hefner VA Medical Center 

Salisbury, North Carolina 

Report No. 07-01796-181 August 2, 2007

VA Office of Inspector General 

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

Call the OIG Hotline – (800) 488-8244 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Contents 

Page 

Executive Summary ..............................................................................................i

Introduction ..........................................................................................................1

Purpose............................................................................................................................. 1

Background...................................................................................................................... 1

Scope and Methodology .................................................................................................. 3

Evaluation Results ...............................................................................................4

Follow-Up to 2005 OMI Recommendations................................................................... 4 

Follow-Up to 2006 OIG Recommendations.................................................................... 4 

Communication and Coordination between OIG and OMI............................................. 5 

Case Review – Delay in Care .......................................................................................... 5 

Environment of Care........................................................................................................ 6 

Performance Measures and Patient Satisfaction.............................................................. 6 

Appendixes

A. Follow-Up Evaluation of 2005 OMI Recommendations........................................... 9

B. Follow-Up Evaluation of 2006 OIG Recommendations ......................................... 16 

C. VISN 6 Director Comments..................................................................................... 20

D. Medical Center Director Comments........................................................................ 21

E. OIG Staff Contact and Acknowledgements............................................................. 23

F. Report Distribution................................................................................................... 24

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Executive Summary 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections, conducted 

a review to follow up on two previous reports: (1) the Office of the Medical Inspector 

(OMI) report, Review of the Delivery of Surgical Services, June 9, 2005, and (2) the OIG 

report, Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical 

Center, Salisbury, North Carolina (Report No. 06-02245-220, September 25, 2006). The 

purpose was to determine whether OMI’s and OIG’s recommendations were 

implemented; we also determined whether adverse conditions identified in those reports 

were resolved or improved. We also evaluated a concern regarding the adequacy of 

communication between OMI and OIG and reviewed an April 2007 hotline complaint 

related to quality of care. We conducted an environment of care (EOC) inspection of 

patient care areas, and we evaluated the medical center’s performance in relation to 

Veterans Health Administration performance measures and patient satisfaction goals. 

We visited the Salisbury VA Medical Center (the medical center) during the week of 

April 9, 2007. We found that medical center managers implemented corrective actions 

that resolved or improved the deficiencies cited in the 2005 OMI report and the 2006 

OIG report. We confirmed that communication processes between OMI and OIG needed 

improvement. We did not substantiate the recent hotline allegation that a patient received 

poor quality of care at the medical center. 

During the course of this review, however, we found two EOC deficiencies in areas that 

were not previously inspected by the OIG or OMI and required management attention. 

We found that private patient bathrooms on the locked mental health units had exposed 

pipes that could pose a safety risk to patients. In addition, we found that tunnels 

connecting buildings on the campus did not have emergency call systems accessible to 

patients or visitors. 

We determined that the medical center’s performance measure scores for the 1st quarter 

2007 met or exceeded established goals in virtually all areas measured. The most recent 

Survey of Healthcare Experiences of Patients results showed that patients were generally 

satisfied, although improvements were still needed in some inpatient areas. 

To enhance patient safety, we made the following recommendations: 

• Ensure that lavatory waste and supply pipes on the mental health units are 

covered. 

• Ensure that an emergency alert system in long connecting tunnels is accessible to 

patients, visitors, and staff. 

VA Office of Inspector General i 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Introduction 

Purpose 

At the request of Chairman Bob Filner of the House of Representatives Committee on 

Veterans’ Affairs (HVAC) and Chairman Harry E. Mitchell of the HVAC Subcommittee 

on Oversight and Investigations, the VA Office of Inspector General (OIG), Office of 

Healthcare Inspections (OHI) conducted a review to follow-up on the Office of the 

Medical Inspector (OMI) report, Review of the Delivery of Surgical Services, June 9, 

2005, and to follow-up on the OIG report, Combined Assessment Program Review of the 

W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina, (Report No. 06-

02245-220, September 25, 2006). The purpose was to determine whether the OMI report 

and the OIG Combined Assessment Program (CAP) recommendations had been 

implemented; in addition, we planned to determine whether adverse conditions identified 

in those reports were resolved or improved. We evaluated a concern about inadequate 

communication between OMI and OIG, and we reviewed an April 2007 hotline 

allegation related to quality of care. We conducted an environment of care (EOC) 

inspection of patient care areas, and we also evaluated the medical center’s performance 

in relation to Veterans Health Administration (VHA) performance measures and patient 

satisfaction goals. 

Background 

The medical center is a tertiary care facility that provides medical, surgical, rehabilitative, 

and nursing home care to veterans in a primary service area that includes 23 counties in 

the Piedmont region of North Carolina. The medical center has 159 hospital beds and 

270 long-term care beds, and it operates community based outpatient clinics in Charlotte 

and Winston-Salem. 

In March 2007, articles appearing in the public media referenced the 2005 OMI report 

and the 2006 OIG report. The articles specifically noted that OMI found surgical care at 

the medical center to be “marginal at best and in some cases, substandard,” and OIG 

found that a VA nurse reported inaccurate clinical information in the medical records of 

veterans in contract community nursing homes (CNHs). 

Chairman Filner, along with North Carolina Representatives Mel Watt, Howard Coble, 

and Robin Hayes, requested that OIG evaluate whether the medical center adequately 

addressed the previous OMI and OIG reports’ recommendations and determine whether 

the previously identified conditions were improved or resolved. 

In addition, Chairman Filner stated his concern that the process to ensure communication 

and accountability between OMI and OIG was deficient. 

VA Office of Inspector General 1 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

2005 OMI Review. In August 2004, an anonymous complainant reported to OIG’s 

Hotline division that over the previous 2-year period, 12 surgical patients died 

unexpectedly at the medical center. OIG, an independent oversight organization, referred 

the case to OMI, VHA’s internal review unit. OIG has oversight responsibility for OMI 

activities and, in an effort to evaluate complaints in a timely manner, occasionally 

requests that OMI undertake medical reviews. The results of these OMI inspections are 

reviewed by OIG. 

The complainant provided specific information on only one case, that of a patient who 

was admitted for a toe amputation but died after improper post-operative care. OMI was 

later contacted by the family of a patient who died at the medical center in 2003. While 

this was a medical patient, not a surgical patient, the OMI accepted this case as well. In 

March 2005, OMI visited the medical center to review the care of these two patients and 

assess the adequacy of surgical services in general. OMI determined that the surgical 

patient received poor post-operative care following a toe amputation and the medical 

patient’s care did not meet standards of care. OMI also found multiple deficiencies 

related to staffing, documentation, communication, and performance improvement (PI) in 

Surgical Service. OMI recommended a number of changes to improve the quality of care 

for surgical patients. 

2005 National Director of Surgery Review. In May 2005, VHA’s National Director of 

Surgery visited the medical center. Since the complainant did not provide the names of 

other surgical patients who allegedly died unexpectedly, the Director of Surgery reviewed 

all surgical deaths that occurred in the previous 2 years. His review did not substantiate 

the allegations. He agreed with OMI that in the surgical index case, the patient received 

poor post-operative care. However, he did not identify quality of care issues for the other 

16 surgical patients who died in fiscal years 2002, 2003, or 2004.1

 

2006 OIG CAP Review. In June 2006, OIG conducted a routine CAP review and found 

deficiencies in CNH program oversight, quality management (QM), and EOC, and made 

recommendations for improvements. OIG did not specifically review Surgical Service 

issues or follow up on OMI’s recommendations from their 2005 report. The 2006 OIG 

CAP report can be accessed at http://www.va.gov/oig/cap/VAOIG-06-02245-220.pdf

2007 Hotline Case. In April 2007, OIG’s Hotline division received a complaint alleging 

poor quality of care. In this case, the complainant reported that her father did not receive 

radiology examinations which would have saved his life. 

In response to the Congressional request and the new hotline allegation of poor care, OIG 

conducted a follow up visit to the medical center the week of April 9–13, 2007. 

 

1

 The deaths were identified through National Surgical Quality Improvement Program (NSQIP) reports. 

VA Office of Inspector General 2 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Scope and Methodology 

Prior to our visit, we reviewed the 2005 OMI report, the report from VHA’s National 

Director of Surgery, and the 2006 OIG report. We interviewed OMI employees who 

conducted a follow-up site visit in March 2007 to evaluate the status of surgical issues at 

the medical center. We also interviewed medical center managers and employees, 

reviewed QM and administrative records, evaluated medical records of selected patients, 

and conducted an EOC inspection. In addition, we assessed the medical center’s 

achievement of VHA performance measure and patient satisfaction goals. We also 

reviewed relevant articles which had appeared in the public media. 

This review was performed in accordance with the Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

VA Office of Inspector General 3 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Evaluation Results 

Overall, we found that conditions identified in the 2005 OMI and 2006 OIG reports were 

resolved or improved. QM and other performance measures indicated that the medical 

center delivered appropriate patient care and patients were generally satisfied with the 

care they receive. The medical center is accredited by The Joint Commission2

 for the 

triennial cycle ending in August 2008. 

Follow-Up to 2005 OMI Recommendations 

Medical center managers implemented corrective actions that resolved or improved the 

deficiencies cited in the 2005 OMI report regarding surgical services. See Appendix A 

on pages 9–15 for the 2005 OMI report recommendations, actions taken, and current 

status. 

We did not review individual surgical cases; rather, we evaluated the medical center’s 

systems and processes designed to ensure that the quality of surgical services and patient 

safety practices met community standards of care. 

Notably, Surgical Service initiated an active PI program, with the following results: 

• In April 2006, the average delay to start the first surgical case of the day was 55 

minutes; in February 2007, the average delay was 15 minutes. 

• The medical center met or exceeded the performance measure target scores 

(1st quarter 2007) for timely administration of antibiotics, use of appropriate 

antibiotics, surgical site hair removal, and normothermia (normal body 

temperature). The medical center scored an 86 (target 87) for the timely 

discontinuation of antibiotics after surgery. 

• According to NSQIP, a repository for surgical complication and outcome data, 

since 2004 the medical center’s surgical morbidity and mortality rate ranked 

substantially lower than the national mean, as follows: 

o In fiscal years (FYs) 2004–2006, the mortality observed to expected (O/E) 

ratio was 0.86; the national mean O/E was 1.00. 

o In FYs 2004–2006, the morbidity O/E was 0.46; the national mean O/E was 

1.00. 

Follow-Up to 2006 OIG Recommendations 

Medical center managers implemented corrective actions that resolved or improved the 

deficiencies cited in the 2006 CAP report. See Appendix B on pages 16–19 for the OIG 

CAP report recommendations, actions taken, and current status. 

 

2

 The Joint Commission was formerly the “Joint Commission on Accreditation of Healthcare Organizations.” 

VA Office of Inspector General 4 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

OMI-OIG Communication and Accountability 

We validated Chairman Filner’s concern that the process to ensure communication and 

accountability between OMI and OIG was deficient. Representatives from OMI and OIG 

have regular meetings in Washington, DC, to discuss OMI cases. However, the Atlanta 

OIG field office, which has regional oversight jurisdiction over the medical center, was 

not aware of OMI activities and did not have access to OMI reports related to the medical 

center. In April 2007, OHI managers posted a spreadsheet of OMI activities on a secure 

network that is accessible to appropriate field office personnel. The spreadsheet is 

updated after all OMI-OIG meetings. 

As OIG has oversight responsibility for OMI activities, all published OMI reports will 

also be available to all OIG field offices for review. Should follow-up of OMI findings 

and recommendations be warranted, appropriate OIG offices will include these elements 

in their project work plans and published OIG reports. 

Case Review – Delay in Care 

In April 2007, OIG’s Hotline division received a complaint from the daughter of a 

deceased veteran alleging that her father received inadequate care at the medical center 

that lead to his demise. The complainant alleged that her father frequently visited the 

medical center requesting radiology examinations due to health concerns. The patient 

was allegedly told that his problems were related to chronic obstructive pulmonary 

disease (COPD) and age-related issues, and the examinations were not ordered. After 

many pleas, the patient underwent a computerized tomography scan (CT) which revealed 

“spots in his head”; her father died soon after this diagnostic test. The complainant 

alleged that if the medical center staff had heeded the patient’s pleas for diagnostic 

testing and medical care, he would not have died. 

Case Summary. The patient was a 70-year-old male with a past medical history of severe 

COPD, depressive neurosis, panic disorder, congestive heart failure, and dementia. The 

patient had been treated at the medical center since 1997. The patient had been exposed 

to asbestos in the Navy; he was also a heavy smoker by social history, smoking two 

packs of cigarettes per day for the last 50 years. 

On February 12, 2003, a CT of the brain revealed what was suspected to be metastatic 

lesions from a primary cancer (site unknown). The patient elected not to complete 

further diagnostic testing or treatment and was transferred to hospice care after his other 

medical conditions stabilized. The daughter was with her father at the time of his death 

on April 9, 2003. The patient’s discharge summary indicates respiratory failure 

secondary to probable lung cancer as the cause of death. The daughter declined an 

autopsy. 

VA Office of Inspector General 5 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

We reviewed the patient’s medical record from 1997-2003 and found no evidence that the 

patient had requested diagnostic x-ray or CT scans at any time. A 1997 CT scan of the 

chest revealed a lung nodule which clinicians monitored; in January 2003, a CT showed 

the nodule to be unchanged from previous reports. Progress notes reflect that clinicians 

closely monitored the patient’s pulmonary condition and addressed his multiple medical 

problems during primary care clinic appointments, emergency room visits, and hospital 

admissions. There is no evidence in the medical record to indicate any delay in testing 

was a contributing cause of death. We found that clinical staff provided appropriate care 

to the patient. 

Environment of Care 

The medical center is comprised of 35 buildings located on 91 acres and was built in 

1952. Despite the size of the campus, multiple buildings, and old construction, the 

facility was generally very clean and well maintained. However, we identified two 

patient safety issues requiring management attention. 

Lavatory pipes in patient bathrooms on the locked mental health units were exposed, thus 

presenting a safety hazard to high-risk patients. The National Association of Psychiatric 

Health Systems guidance booklet states, “All lavatory waste and supply piping must be 

enclosed and should not be accessible to patients.” 

We also found that many of the medical center’s buildings were connected by long 

tunnels or enclosed passageways. While phones were located in the tunnels, they were 

only accessible to staff with appropriate keys. Patients and visitors had no way to call for 

help in the event of an emergency. 

Performance Measures and Patient Satisfaction 

VHA performance measures demonstrate a medical facility’s compliance with clinical 

practice guidelines that are designed to achieve high quality health outcomes reliably and 

efficiently. Performance measures set national benchmarks for the quality of preventive 

and therapeutic healthcare services in areas such as ischemic heart disease, diabetes, and 

COPD. VHA uses comparative data from within the organization and from the private 

sector to hold managers accountable for less than optimal performance, and to 

demonstrate best practices in health care delivery. 

Overall, the medical center’s performance measure scores met or exceeded standards. In 

the 1st quarter 2007, the medical center had only a few outliers, primarily related to 

access to specialists. In each case, a “champion” for that measure submitted an action 

plan to improve scores. The tracking of performance measure scores, corrective actions, 

and follow-up was excellent. 

VA Office of Inspector General 6 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

The Survey of Healthcare Experiences of Patients (SHEP) is aimed at capturing patient 

perceptions of care in 12 service areas, including access to care, coordination of care, and 

courtesy.3

 VHA relies on the survey data to improve the quality of care delivered to 

patients. In general, the medical center’s outpatient SHEP scores met or exceeded goals 

in the 1st quarter 2007. The medical center was underperforming in the area of “specialist 

care,” possibly because many specialties are not available at the medical center, and 

patients must be referred to other VA or private facilities for care. At the time of our 

visit, the medical center was recruiting for an orthopedist, cardiologist, and 

gastroenterologist. For the 3rd and 4th quarters 2006 (the most recent data available), the 

medical center’s inpatient scores did not meet established goals in five areas. We found 

that the medical center’s SHEP program was not fully developed at the time of our visit, 

and managers had only recently established a system to review and disseminate SHEP 

data for follow-up and improvement actions. 

Conclusion 

Medical center managers implemented corrective actions, and those conditions identified 

in the 2005 OMI and the 2006 OIG reports have resolved or improved. The systems and 

processes to ensure quality surgical services and patient safety practices have improved, 

and surgical PI activities reflected substantial compliance with VHA performance 

measures. Medical center managers took appropriate action to ensure that CNH patients 

received nursing visits in accordance with policy and that VA CNH Program staff 

increased the oversight of underperforming CNHs. 

We confirmed that while the OMI and OIG had regular meetings, the OIG field office 

responsible for the Salisbury, NC, area was not aware of OMI activities related to the 

medical center’s surgery program. Actions have been initiated to ensure that OIG field 

offices have access to and follow up on OMI reports. 

We did not substantiate a complaint of delayed care; rather, we determined that the 

patient received appropriate evaluation and treatment. 

During the course of our review, we noted that patient bathrooms on the locked mental 

health units had exposed lavatory waste and supply pipes. In addition, patients and 

visitors did not have access to emergency call systems in long tunnels that connected 

many of the medical center’s buildings. Both of these conditions presented patient safety 

risks and required management attention. 

As evidenced by performance measure and patient satisfaction scores, it appears that the 

medical center delivers appropriate patient care and that patients are generally satisfied 

with the care they receive. 

 

3 vaww.oqp.med.va.gov It should be noted that information referenced from this website is a VA intranet site not 

available outside the VA system. 

VA Office of Inspector General 7 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 8 

Recommendations 

To enhance patient safety, we made the following recommendations: 

Recommendation 1. We recommend that the VISN Director ensure that the Medical 

Center Director requires that lavatory waste and supply pipes on the mental health units 

are covered. 

Recommendation 2. We recommend that the VISN Director ensure that the Medical 

Center Director implements an emergency alert system in long connecting tunnels that is 

accessible to patients, visitors, and staff. 

Comments 

The VISN and Medical Center Directors agreed with our findings and recommendations 

and provided acceptable improvement plans. Actions have been initiated to retrofit the 

mental health units’ bathrooms with protective coverings so that pipes are not accessible. 

The Mental Health Service has developed an interim staffing plan to ensure appropriate 

supervision of high-risk patients pending completion of the structural changes. In 

addition, emergency call boxes have been installed in connecting tunnels. See pages 

20–22 for the Directors’ comments. We will follow up until the planned actions are 

completed. 

 (original signed by:) 

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

Assistant Inspector General for 

Healthcare Inspections 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Follow-Up Evaluation of Clinical Issues 

Salisbury, North Carolina 

OMI REPORT, Review of the Delivery of Surgical Services, June 9, 2005 

The following matrix shows the primary issues and recommendations as identified in the 2005 OMI report and 

conditions and recommendations. 

Report Issues 2005 OMI 

Report Recommendations 

Status as of March 30 , 2007 

Action(s) Taken 

The peer review committee (PRC) process is not clearly defined. 

Policy should define the roles and responsibility of the PRC members and the peer review process. 

Resolved PRC policy MCM 

Program, dated Fdescribes the peedefines roles and PRC members. 

Root cause analyses (RCAs) did not identify all root causes of an event. 

Identify all root causes in the RCA process. 

Resolved The National Cen

(NCPS) reviews provides feedbacRCA teams receitraining to identifevent. The NCPS conduinspection on Maassessed 45 standencompassed leadstaffing, resourcePatient Safety Regeneral program and advisories. Oof the 45 was not 

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

clerical support fsafety reports into Information SysteThree staff membNCPS Patient Sathe Spring of 200Officer (PSO) paRCA training witSeptember 2006. attended a nation

Progress notes for a patient were copied and pasted with the same content on successive days in the computerized patient record system (CPRS). 

All progress notes should be in compliance with policy and reflect current clinical information for the patient on the day the note is entered. 

Resolved MCM 136-5, Con

Release of MedicInformation, dateaddresses the copAn addendum waMedical Staff Byprohibiting the uspasting. All provstatements acknowould not copy aThe Medical Rec(MRC) monitors copying and pastare presented at t

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

Patients and their families are not informed of adverse events per VHA Handbook 1050.1 requirements. 

Develop and implement a disclosure policy. 

Resolved MCM 11-44, Dis

Events to Patient2006, was develoThe Chief of Stafof the two originaidentified to discloutcomes. Managers providof patient progresdisclosure. 

Family members did not know the results of autopsies. 

Autopsy results need to be communicated to family members by a designated member of the healthcare team. 

Resolved An addendum wa

staff by-laws statphysicians are reqautopsy to the famhave died at the mattending physicifamilies, or other individuals, of thin a timely manneThree autopsies w2006, and documfamilies were infNo autopsies had April 13, 2007. 

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

Performance improvement is lacking in Surgery Service; Morbidity & Mortality (M&M) conferences did not take place. 

Surgery Service should conduct M&M conferences and other PI activities. 

Resolved M&M occurs at l

recently, has occuminutes reflect dodiscussions. A nurse is assignmonitor PI proceAll operating rooinvolved in the Pstaff completed thTraining, a Patiencommunication. 

Medications in the OR were unsecured. 

Secure all medications as required. 

Resolved An Omnicell, a d

controls and secumedications, was anesthesia care urolling cart with tprovided. All mehave locks. All medications amedication cabinprocedure room. 

Surgery Service does not notify the PSO of unexpected events. 

Surgery staff should participate in the patient safety program for the medical center. 

Resolved An anonymous e

Incident Reportinplace. 

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

Surgical staff parteams. The NSQIP nurse surgery and identevents during or f

The PACU is staffed by cross trained OR nurses and lacks a regularly assigned nursing staff. 

Assign permanent nursing staff to the PACU. 

Resolved A permanent staf

assigned to the PAManagers initiatefor the PACU nuproviding 24/7 co

Nurses on the surgical inpatient unit did not have competencies reviewed and verified annually. 

Ensure that surgical nurses have competencies verified annually. 

Resolved Twenty-four of 2

folders we reviewless than 30 days 

Committee meeting minutes did not identify action items for follow up. 

Committee minutes need to reflect discussion, action items and the individuals responsible for follow-up, and action item completion/outcomes. 

Resolved The format for co

changed to reflecdiscussion/findinrecommendationsresponsibility, anA template of the was available to sicon. Our review of co

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

showed staff usin

Critically ill patients are not transferred in a timely manner during nonadministrative hours. 

All staff should be educated on the process for transferring patients. 

Resolved Managers establi

approach to handusing an ISBAR Situation, Backgrand Recommendmaintained in a foeach hospitalist, MDay (MOD), and Surgeons now coduring non-adminthe nurses call theThe MOD providfor all patients in and works with thOfficer of the Dapatient’s transfer clinical judgmentAttachment A of Medical Officer oOctober 15, 2004

Medical center policy does not address physician coverage during nonadministrative hours. 

Develop a policy defining physician coverage during non-administrative hours. 

Resolved MCM, 11A-6, M

Day, outlines the responsibilities focare to patients dadministrative ho

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner V

Report Issues 2005 OMI 

Report Recommendations 

Status as of Action(s) Taken March 30 , 2007 

Surgeons cover thcontract physiciapatients. There is an on-cahospitalists, cardiso the contract phto contact if needE-mail regarding schedules is sent numbers are poststation. The AOD schedules. 

Physicians performing procedures with conscious sedation (CS) did not have the appropriate privileges. 

Physicians need to have privileges to perform CS. 

Resolved The Credentialing 

folders of the ninCS included the adocumentation of 

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medic

Follow-Up Evaluation of Clinical Issues 

Salisbury, North Carolina 

OIG REPORT, Combined Assessment Program Review of the VA Medical Center, Salisbury, NC, S

The following matrix shows the primary issues and recommendations as identified in the 2006 OIG current status of those conditions and recommendations. 

Report Issues 2006 OIG CAP 

Report Recommendations 

Status as of 

April 9, 2007 

Action

The VA CNH Program nurse did not perform regular visits to monitor patients in CNHs. (This issue also involved the nurse reporting inaccurate clinical information in CNH patients’ records.) 

Ensure VA CNH Program nurses visit patients in contract facilities at least quarterly and as clinically appropriate. 

Resolved Appropriate action 

the nurse who did as well as against A half-time registeposition has been visitation is occurrdays, and every 30 need of additional on the Watch Listmore often if cliniA nursing clinical responsible for dirthe RN until a new Coordinator is app

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medic

Report Issues 2006 OIG CAP 

Report Recommendations 

Status as of Action

April 9, 2007 

VA CNH Program staff did not increase monitoring of veterans in substandard CNHs. 

Ensure that CNH Program staff increase monitoring of substandard CNHs where veterans are under contract. 

Improved An electronic tickl

established to ensucompletion of the The CNH team revmonthly and reporOversight CommiCommittee minuteClinical Executive The social worker joint monthly visitWatch List every 3this doubles the nueach discipline, walternating the socvisits (instead of a further improve thmonitoring. The team was also increase monitorinthe Exclusion Revmany quality mea

The Peer Review Committee (PRC) did not complete the quarterly tracking of peer review activities as required 

Ensure that the PRC completes quarterly tracking of peer review activities. 

Resolved The summary of P

revised to include of cases that resultfindings. 

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medic

Report Issues 2006 OIG CAP 

Report Recommendations 

Status as of Action

April 9, 2007 

in VHA Directive 2004-054. 

The PRC met six tvisit in June 2006. discussion of levelproviders, changes actions, responsibltarget dates for coThe PRC presentelevels, findings, trrecommendations and September 202007. 

RCAs did not have measurable outcomes and/or did not measure effectiveness of actions taken. The RCAs did not have concurrence signatures by all appropriate staff. 

Ensure that RCAs have measurable outcomes and effectiveness of actions is evaluated. Ensure that RCA team members sign completed RCAs. 

Improved RCAs have measu

due dates that suppaction plans. VISN 6 provided tSafety Managers aselected action plaPatient Safety peeThe NCPS provideselected RCAs. RCA team leaders obtain all team meprior to presentatio

VA Office of Inspector General 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medic

VA Office of Inspector General 

Report Issues 2006 OIG CAP 

Report Recommendations 

Status as of 

April 9, 2007 

Action

Center Director. Rcontained the nece

Administrative Boards of Investigation (ABIs) did not have all of the team member signatures and did not include the convening authority certificate of completion. 

Ensure all ABIs have certificates of completion and all team members sign the completed reports. 

Resolved Certificates of com

to all ABIs and the each ABI has been all member signatupresentation of the reviewed four recethe appropriate do

The main Nutrition and Food Service (N&FS) kitchen ceiling and air diffusers were not clean. 

Ensure that the N&FS kitchen ceiling and air diffusers are cleaned regularly and a system for monitoring compliance is in place. 

Resolved N&FS added clean

to weekly cleaning time of our inspecdiffusers were cleaN&FS added the cmonthly Sanitationof the food producFMS added air difheads in N&FS kiannual preventive schedule. 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix C 

VISN 6 Director Comments 

Department of 

Veterans Affairs Memorandum

Date: July 26, 2007 

From: Director, VA Mid-Atlantic Health Care Network (10N6) 

Subject: Follow-Up Evaluation of Clinical Issues, W.G. (Bill) Hefner 

VA Medical Center, Salisbury, NC; Project Number 2007-

01796-HI-0323

To: Office of Inspector General 

Thru: Director, Management Review Office (10B5) 

 

1. VISN 6 has reviewed and concurs with the draft report. 

The VISN Office is closely monitoring completion of the 

action items related to covering lavatory and supply 

pipies and that interim measures have been put into place. 

Also, note that action related to the emergency alert 

system has been completed. 

2. I would also add that if they have questions, please 

contact the Network Director. 

 (original signed by:) 

DANIEL F. HOFFMANN, FACHE 

VA Office of Inspector General 20 
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC

Appendix D 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: July 25, 2007 

From: Director, W.G. (Bill) Hefner VA Medical Center (659/00) 

Subject: Follow-Up Evaluation of Clinical Issues, W.G. (Bill) 

Hefner VA Medical Center, Salisbury, NC; Project 

Number 2007-01796-HI-0323

To: Director, VA Mid-Atlantic Health Care Network (10N6) 

The following Director’s comments are submitted in response 

to the recommendation(s) in the Office of Inspector General’s 

Report: 

1. This is to acknowledge receipt and thorough review of the 

Office of Inspector General Follow-Up Evaluation draft 

report. I concur with all recommendations for improvement 

identified in the report. 

2. The responses and action plans for each recommendation 

are enclosed. 

3. Should you have any questions regarding the comments or 

implementation plans, please contact me at (704) 638-9000 ext. 

3344. 

 (original signed by:)

CAROLYN L. ADAMS 

Director, Salisbury VA Medical Center 

VA Office of Inspector General 21
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC

Appendix D 

Medical Center Director Comments 

OIG Recommendation(s) 

Recommendation 1. We recommend that the VISN Director 

ensure that the Medical Center Director requires that lavatory 

waste and supply pipes on the mental health units are covered. 

Concur Target Completion Date: October 31, 2007 

The toilets and sinks on the Mental Health units will be 

retrofitted with a commercially made protective covering to 

provide patient safety. The estimated cost is $190,000. 

 

The Mental Health Service Line has developed an interim plan 

with staffing to ensure appropriate supervision/monitoring of 

patients in areas of high risk e.g. bathrooms, to help ensure 

patient safety until the structural changes can be made. 

 

Recommendation 2. We recommend that the VISN Director 

ensure that the Medical Center Director implements an 

emergency alert system in long connecting tunnels that is 

accessible to patients, visitors, and staff. 

Concur Target Completion Date: Completed. 

The installation of two way communication emergency call 

boxes has been completed throughout the tunnel system in 

Salisbury. The RED Emergency Call Boxes, when activated, 

will connect the caller to the Telephone Operator who will 

dispatch the call to the Police Service. They function by 

pushing a button once to alert the operator which permits two 

way communications. The four number phone extension of the 

call box reveals the location of the call. This information has 

been communicated to all staff. 

VA Office of Inspector General 22
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix E 

OIG Contact and Staff Acknowledgments 

OIG Contact Victoria Coates, Director 

Atlanta Office of Healthcare Inspections 

(404) 929-5961 

Acknowledgments David Griffith 

Jerome Herbers, M.D. 

Christa Sisterhen 

Susan Zarter 

VA Office of Inspector General 23
Follow-Up Evaluation of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC

Appendix F 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Health Care Network (10N6) 

Director, W.G. (Bill) Hefner VA Medical Center (659/00) 

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. Senate: Elizabeth Dole, Richard Burr 

U.S. House of Representatives: Mel Watt, Howard Coble, Robin Hayes 

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

VA Office of Inspector General 24