Healthcare Inspection - Oversight Review of Anesthesia and Management Issues, Sacramento VA Medical Center, Mather, California

OIG conducted an oversight inspection to review actions taken to address a complainant’s allegations that an anesthesiologist provided inadequate care to two patients, leadership did not take effective actions to address Anesthesia Service operational issues, and providers breached patient privacy policy at the Sacramento VA Medical Center (the facility) in Mather, CA. OIG did not substantiate the allegation that the subject anesthesiologist provided inadequate anesthesia care. OIG substantiated the allegations that facility leaders had not taken effective actions to resolve Anesthesia Service’s operational issues and that facility providers’ breached patient privacy and VA information security policies. OIG recommended that the Facility Director (1) Comply with the Anesthesia Service’s leadership and staffing requirements as detailed in the VISN Team report, (2) Implement processes to formally monitor patient outcomes in the operating room (OR) and promote a culture of patient safety in the OR, and address the concerns raised by the VISN team in its review of the Surgery and Anesthesia Services, and (3) Consult with Regional Counsel to determine whether patient notification of a breach in privacy is required. Management agreed with the recommendations and provided acceptable action plans.