Telepeer

Federal watchdog finds VA Loma Linda lacked policy for informing patients of test results

April 10, 2026

A federal watchdog has found that the VA Loma Linda Healthcare System lacked a written policy for communicating medical test results to patients, raising serious patient safety and accountability concerns.

During an inspection of the hospital from April 28 through May 1, 2025, the U.S. Department of Veterans Affairs Office of Inspector General found that not only did the hospital not have a documented policy outlining how physicians and staff should communicate test results to patients, but was unable to show any progress toward developing one, according to a March 12 OIG report.

The report found repeated gaps in leadership response to known issues.

In December 2024, a patient safety manager alerted the chief of staff that providers often were unaware of requirements for communicating test results and frequently failed to properly document or share them. According to the report, the concerns were not resolved, and no standardized process was in place to ensure results consistently reached patients and providers.

Hospital leaders cited several reasons for the failure, including competing demands, a two-year vacancy in the position overseeing quality and patient safety, and the absence of a structured process to review and communicate updates to Veterans Health Administration policies, according to the report.

The report also highlighted confusion over oversight responsibilities within the Veterans Health Administration. A quality management officer with the Veterans Integrated Service Network, which oversees multiple VA facilities, expected program leaders to work with hospital leadership to ensure compliance with requirements for communicating test results.

When OIG investigators asked about this review, both the chief of staff and the associate director of patient care services said they were unaware of it. However, email records show both were included in related communications sent to the Quality and Patient Safety Council distribution list, contradicting their statements.

The OIG noted that the facility’s peer review process did produce quarterly data on test result communications, and the peer review coordinator routinely notified leadership when providers failed to share results. Nonetheless, the chief of staff acknowledged that the facility did not conduct formal audits of test result communications and instead relied on staff to report problems, according to the audit.

VA Loma Linda officials concurred with the findings and outlined plans to address the deficiencies. It is developing a written policy and accompanying step-by-step procedures to ensure medical test results are communicated effectively to both patients and providers. Drafts of the policy are currently under review, according to the report.

To strengthen oversight, hospital leaders agreed that the chief of staff and associate director of patient care services will regularly review how test results are communicated and address any problems found. The hospital will also randomly review 30 outpatient charts each month, report the findings to its patient safety council, and continue tracking progress until it consistently reaches 90% compliance for six straight months, the report states.

Investigators also learned that senior hospital leaders were not consistently attending key patient safety meetings. The Office of Inspector General found that executives, including the chief of staff and associate director of patient care services, often missed these meetings over a 10-month period in 2024 and 2025. The meetings are meant to oversee quality of care and ensure patient safety standards are being met, according to the report.

Hospital administrators agreed and said they have since updated their policies to ensure executive leaders attend these meetings as required. They also told the OIG that attendance will be tracked monthly and that they aim to achieve attendance at 90% or higher for six months.

The OIG issued eight recommendations in all, which also included improving cleanliness and safety in patient care areas, strengthening privacy protections in the emergency department, and ensuring eyewash stations are properly maintained. The report also called for stronger leadership accountability.

VA Loma Linda concurred with all recommendations “and has already implemented or is on the way to implementing these recommendations,” VA Press Secretary Quinn Slaven said in an email.

Anchored by the Jerry L. Pettis Memorial Veterans Hospital in Loma Linda, the VA Loma Linda Healthcare System provides medical services to more than 78,000 veterans residing in San Bernardino and Riverside counties, and also includes seven outpatient clinics and an ambulatory care center.

The report is the latest in a series of findings over the past decade highlighting broader challenges at the federally funded hospital.

In September 2025, an OIG audit found that 69% of appointments at VA Loma Linda outpatient clinics were canceled over a two-year period due to staffing shortages and poor oversight, affecting health care for thousands of veterans. The findings add to years of scrutiny over the facility’s management and highlight ongoing access and care challenges.

A 2023 survey found many VA Loma Linda employees were uncomfortable reporting misconduct due to fear of retaliation, lack of trust in leadership, and concerns that complaints would not be taken seriously or could negatively affect their careers. Just 27% of respondents who reported wrongdoing to VA Loma Linda’s executive leadership team believed their complaints were taken seriously and properly addressed. Additionally, 78% of more than 900 survey respondents said inaction by management poses a significant barrier to filing grievances.

Orange County Register

News Details

Federal watchdog finds VA Loma Linda lacked policy for informing patients of test results

Leave a Reply Cancel reply

News

CONTACT INFO

QUICK LINKS

SERVICES

CURRENT NEWS