Inadequate Care Coordination at the VA Southern Nevada Healthcare System in Las Vegas
Veteran Oversight NowShow Notes
In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.
“If you go by the timeline, this is 17 days after the patient’s first visit to the emergency room with the shortness of breath problems. . . . Unfortunately, the patient completed suicide that same day without receiving the medication.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director
This podcast edition also includes highlights of the VA OIG’s work from June 2024.
Related Report: Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas
More from Veteran Oversight Now
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In August 2025, the VA OIG published 17 reports that included 72 recommendations to VA.
The Honorable Cheryl L. Mason was confirmed by the Senate as the inspector general of the VA on July 31, 2025, and shortly after being sworn in, took up her leadership of the VA OIG on August 4. IG Mason previously served as the chairman of the Board of Veterans’ Appeals at VA. For more information on IG Mason, see her bio.
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In June 2025, the VA OIG published nine reports that included 81 recommendations. Report topics varied from an evaluation of VA’s governance of recruitment, relocation, and retention incentives awarded for VHA positions to mental health inspections of the VA Salem Healthcare System in Virginia and the VA Philadelphia Healthcare System in Pennsylvania.
Each month, the VA Office of Inspector General publishes highlights of our oversight reports, congressional testimony, and investigative work. In May 2025, the VA OIG published 11 reports that included 54 recommendations. Report topics varied from an audit of the VHA’s Pain Management, Opioid Safety, and Prescription Drug Monitoring Program to a healthcare inspection to assess allegations of deficiencies in the emergency department care provided to a patient at the Martinsburg VA Medical Center in West Virginia.
This Semiannual Report to Congress summarizes the independent oversight efforts of the VA Office of Inspector General (OIG) from October 1, 2024, through March 31, 2025. Visit the VA OIG's website to read the full report.