Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00599-438 | Combined Assessment Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges.
Closure Date:
2 We recommended that the Critical/Acute Care and Transfusion Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee collects code data.
Closure Date:
3 We recommended that the Surgical Quality Committee meet monthly, document its review of National Surgical Office reports, and review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
4 We recommended that the facility keep the recipient list for the critical incident automated e-mail notification current.
Closure Date:
5 We recommended that the recently initiated Accident Review Board provide oversight of the safe patient handling program and gather, track, and share patient handling injury data.
Closure Date:
6 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
Closure Date:
7 We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
Closure Date:
8 We recommended that facility managers ensure fire extinguishers in all patient care areas have documented monthly safety checks and monitor compliance.
Closure Date:
9 We recommended the facility complete and document an annual review of the Hazard Vulnerability Assessment.
Closure Date:
10 We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
11 We recommended that nursing reviewers sign the monthly medication inspection forms for the intensive care and inpatient general medicine units and that facility managers monitor compliance.
Closure Date:
12 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
13 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees consistently post patients’ advance directives status correctly and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the intensive care unit.
Closure Date:
16 We recommended that the facility revise the emergency airway management policy to include the type of clinical staff whose expected duties would include emergency airway management.
Closure Date:
17 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required components and that facility managers monitor compliance.
Closure Date:
18 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
19 We recommended that facility managers ensure video laryngoscopes are available for immediate clinician use and monitor compliance.
Closure Date:
20 We recommended that the facility ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
Closure Date:
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| 15-00533-440 | Healthcare Inspection – Delay in Emergency Airway Management and Concerns about Support for Nurses, VA Northern California Health Care System, Mather, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that staff provide patients information on and assistance with completing advance directives.
Closure Date:
2 We recommended that the Facility Director ensure that corrective action plans concerning clinical warnings, including code status, on patients' wristbands are fully implemented and that managers monitor compliance.
Closure Date:
3 We recommended that the Facility Director instruct nurse managers to conduct an inspection and ongoing monitoring of all inpatient units to ensure nurses do not make copies of wristbands for medication administration.
Closure Date:
4 We recommended that the Facility Director conduct an evaluation of the medical-surgical unit to determine if there are issues undermining psychological safety at the work place and take action to address those issues.
Closure Date:
5 We recommended that the Facility Director develop and implement a plan for employee support following traumatic events.
Closure Date:
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| 15-00130-432 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Kenosha CBOC.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers and providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
7 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their abnormal laboratory results.
Closure Date:
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| 15-00132-430 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the staff at theBrownwood CBOC receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic
assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
4 We recommended that clinic staffconsistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that ClinicRegistered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that providers in theoutpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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| 15-00144-426 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
5 We recommended that the facility director ensures that the facility's written policy for the communication of laboratory results include all required elements
Closure Date:
6 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
7 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
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| 15-00598-446 | Combined Assessment Program Review of the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
2 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
3 We recommended that the Medical Emergency Committee review each code episode.
Closure Date:
4 We recommended that the Accident Review Board Committee share patient handling injury data.
Closure Date:
5 We recommended that the quality control policy/process for scanning include an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
Closure Date:
6 We recommended that the facility clean and/or repair soiled and/or damaged wheelchairs in patient care areas or remove them from service.
Closure Date:
7 We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Controlled Substances Coordinator provide quarterly trend reports to the Facility Director.
Closure Date:
9 We recommended that controlled substances inspectors consistently inspect all required non-pharmacy areas with controlled substances and that the Controlled Substances Coordinator monitor compliance.
Closure Date:
10 We recommended that facility managers ensure the Controlled Substances Coordinator sufficiently rotates controlled substances inspectors in inspection assignments and monitor compliance.
Closure Date:
11 We recommended that controlled substances inspectors complete inspections on the same day initiated and that the Controlled Substances Coordinator monitor compliance.
Closure Date:
12 We recommended that the Facility Director ensure that the controlled substances inspection program has adequate oversight and complies with Veterans Health Administration policy.
Closure Date:
13 We recommended that Domiciliary Care for Homeless Veterans Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
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| 15-00596-429 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
2 We recommended that the Surgical Work Group meet monthly.
3 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, and a complete review of scanned documents to ensure readability and retrievability.
4 We recommended that the facility consistently document actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in the Quality, Safety, and Value; Critical Care; Medical Records; and Infection Prevention and Control Committees and in the Environment of Care Council.
5 We recommended that employees offer patients the opportunity to review, revise, or rescind previously completed advance directives and document the discussions and that facility managers monitor compliance.
6 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
7 We recommended that facility managers ensure that respiratory therapy employees have 12-lead electrocardiogram competency assessment and validation completed and documented.
8 We recommended that the facility revise the emergency airway management policy to include an alternative for new employees, transfers from other VA medical centers, consultants or without compensation clinicians, and the availability of portable video laryngoscopes for use by clinicians for emergency airway management.
9 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of successful demonstration of all required procedural skills on patients and that facility managers monitor compliance.
10 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
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| 15-00602-425 | Combined Assessment Program Review of the Iowa City VA Health Care System, Iowa City, Iowa | Comprehensive Healthcare Inspection Program | ||
1 We recommended that pharmacy personnel conduct and document monthly medication storage area inspections and that facility managers monitor compliance.
Closure Date:
2 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
3 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
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| 14-00903-422 | Healthcare Inspection – Quality of Care Issues, Sheridan VA Healthcare System, Sheridan, Wyoming | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that staff comply with Veterans Health Administration and facility policies and practices related to the management of dysphagia, including assessment and documentation of a patient's response to the provided care recommendations and aspiration risk precautions.
Closure Date:
2 We recommended that the Facility Director implement applicable recommendation(s) from previous event-related reviews, if any.
Closure Date:
3 We recommended that the Facility Director review local privileging processes and ensures compliance with local policy and Veterans Health Administration Handbook 1100.19.
Closure Date:
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| 15-00138-392 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Haverhill CBOC receive
the required training on hazardous materials.
Closure Date:
2 We recommended that CBOC staff minimize the risk of infection
when storing and disposing of medical (infectious waste) at the Haverhill CBOC.
Closure Date:
3 We recommended that the information technology server closet
at the Haverhill CBOC is maintained according to information technology safety and security standards.
Closure Date:
4 We recommended that testing of the panic alarm system is conducted at the Haverhill CBOC.
Closure Date:
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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15160