Lessons Learned after Patient Death following a Fall in a Las Vegas VA Outpatient Clinic

In this latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023.       “Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline DirectorRelated Report: Episode Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas

Published: 6/28/2023Report #22-02725-132