Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02527-23 | Healthcare Inspection – Alleged Nursing Deficiencies Led to Patient's Death, Hampton VA Medical Center, Hampton, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director conduct and document a review to evaluate patient rounds and documentation policies.
Closure Date:
2 We recommended that the Facility Director educate and train all staff regarding patient rounds policies.
Closure Date:
3 We recommended that the Facility Director consult with Regional Counsel regarding institutional disclosure to the patient’s next-of-kin in accordance with VHA Handbook 1004.08.
Closure Date:
| ||||
| 14-02076-13 | Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
Closure Date:
2 We recommended that the local observation bed policy be revised to include how the responsible provider is determined and that each observation patient must have a focused goal for the period of observation.
Closure Date:
3 We recommended that processes be strengthened to ensure that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly, consistently include the Chief of Staff and operating room manager as members, and document its review of National Surgical Office reports.
Closure Date:
5 We recommended that processes be strengthened to ensure that the quality of entries in the electronic health record is reviewed at least quarterly.
Closure Date:
6 We recommended that the quality control policy for scanning include the handling of external source documents.
Closure Date:
7 We recommended that processes be strengthened to ensure that the Transfusion Committee members from Surgery, Medicine, and Anesthesia Services consistently attend meetings and that the blood/transfusions usage review process consistently includes the results of proficiency testing, the results of peer reviews when transfusions did not meet criteria, and the results of inspections by government or private (peer) entities.
Closure Date:
8 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that post-anesthesia care unit employees do not consume beverages in treatment areas and that compliance be monitored.
Closure Date:
11 We recommended that the facility's stroke policy be revised to address data gathering for analysis and improvement, that the policy be fully implemented, and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
13 We recommended that stroke guidelines be posted on the intensive care unit, on the medical/surgical unit, and in the community living center.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
15 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that compliance be monitored.
Closure Date:
17 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents' care plans and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that staff document the reasons for discontinuing or not providing restorative nursing services when those services are care planned and that compliance be monitored.
Closure Date:
20 We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Closure Date:
21 We recommended that processes be strengthened to ensure that contrast reaction emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
Closure Date:
23 We recommended that processes be strengthened to ensure that secondary patient safety screening forms are signed by the patient, family member, or caregiver and that compliance be monitored.
Closure Date:
24 We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
Closure Date:
25 We recommended that processes be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
| ||||
| 14-02074-06 | Combined Assessment Program Review of the Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Quality, Safety, and Value Council meet monthly.
Closure Date:
2 We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Staff Council.
Closure Date:
3 We recommended that the Medical Staff Council discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Cardiopulmonary Resuscitation Committee collects code data.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Transfusion Review Committee members from Medicine and Anesthesia Services consistently attend meetings.
Closure Date:
6 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
Closure Date:
7 We recommended that processes be strengthened to ensure that all food service employees use hairnets and gloves when serving food.
Closure Date:
8 We recommended that all privacy curtains in same day surgery and on the post-anesthesia care unit have open mesh tops that extend 18 inches for sprinkler coverage.
Closure Date:
9 We recommended that same day surgery have designated rooms for the storage of dirty instruments, equipment, and housekeeping supplies and that these rooms and the soiled utility room on the post-anesthesia care unit be secured.
Closure Date:
10 We recommended that processes be strengthened to ensure that designated eye clinic employees receive eye laser safety training annually and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance is monitored.
Closure Date:
12 We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
14 We recommended that stroke guidelines be posted in the emergency department, on the intensive care unit, and on the acute inpatient units.
Closure Date:
15 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
16 We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
17 We recommended that processed be strengthened to ensure that all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
Closure Date:
| ||||
| 14-02077-01 | Combined Assessment Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
2 We recommended that processes be strengthened to ensure that results of Focused Professional Practice Evaluations for newly hired licensed independent practitioners are consistently reported to the Medical Executive Board.
3 We recommended that processes be strengthened to ensure that Cardiopulmonary Resuscitation Review Committee code reviews include screening for clinical issues prior to the event that may have contributed to the occurrence of the code.
4 We recommended that the Surgical Quality Work Group meet monthly.
5 We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Morbidity and Mortality Committee.
6 We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
7 We recommended that processes be strengthened to ensure that Environment of Care Board minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
8 We recommended that processes be strengthened to ensure that the surveillance monitoring systems on the locked mental health units at the York campus are functional and that regular inspections are documented.
9 We recommended that processes be strengthened to ensure that chemicals stored on the dialysis unit at the Nashville campus are secured at all times and that compliance be monitored.
10 We recommended that processes be strengthened to ensure that the negative pressure control systems in the post-anesthesia care unit isolation rooms at both campuses are functional and that compliance be monitored.
11 We recommended that a laser warning sign be posted on the door in the eye clinic laser room at the York campus and that compliance be monitored.
12 We recommended that processes be strengthened to ensure that providers complete and document patient discharge instructions and that compliance be monitored.
13 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
14 We recommended that the facility develop an acute ischemic stroke policy that addresses all required items, that the policy be fully implemented, and that compliance be monitored.
15 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
16 We recommended that stroke guidelines be posted on the intensive care and inpatient medical units.
17 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
18 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
19 We recommended that the facility collect and report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
20 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion and resident transfers.
| ||||
| 14-02070-305 | Combined Assessment Program Review of the Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Inpatient Management Committee reviews each code episode and that code data is collected.
Closure Date:
2 We recommended that the Surgical Review Committee document its review of National Surgical Office reports and monitoring of surgery performance improvement activities.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Blood Usage, Surgical, and Other Invasive Procedures Review Committee members from Medicine, Surgery, and Anesthesia Services consistently attend meetings.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and in good repair and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that public restrooms are clean and in good repair and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all designated same day surgery and eye clinic employees receive laser safety training in accordance with facility policy and that compliance be monitored.
Closure Date:
7 We recommended that the facility¿s stroke policy be revised to address the difference in approach to patients presenting with symptoms within the facility's defined timeframe to be eligible for tissue plasminogen activator and those presenting outside the defined timeframe and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
11 We recommended that the facility collect and report to VHA and the Executive Committee of the Medical Staff the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
12 We recommended that the facility offer restorative nursing services and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that emergency drills are conducted in magnetic resonance imaging and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that initial patient safety screenings are conducted and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that compliance be monitored.
Closure Date:
17 We recommended that the facility designate Level 1 ancillary staff, that processes be strengthened to ensure that Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training, and that compliance with training be monitored.
Closure Date:
18 We recommended that appropriate signage be in place to identify magnetic resonance imaging Zones III and IV.
Closure Date:
| ||||
| 14-02071-02 | Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Resuscitation Services Committee reviews each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
2 We recommended that processes be strengthened to ensure that Environment of Care Committee minutes and the environment of care rounds database accurately reflect whether deficiencies were resolved.
Closure Date:
3 We recommended that processes be strengthened to ensure that patient care areas and public restrooms are clean and free from offensive odors and walls, counters, floors, and furnishings in these areas are in good repair and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that equipment items receive appropriate maintenance and preventive maintenance and electrical inspections stickers are current and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and medications are secured at all times and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake and that patients are provided with printed stroke education upon discharge and that compliance be monitored.
Closure Date:
11 We recommended that the facility collect and report to the Medical Executive Committee the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
12 We recommended that processes be strengthened to ensure that staff include restorative nursing goals and interventions in residents’ care plans and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete required restorative nursing interventions and document the interventions with the frequency established by facility policy, that documentation reflects progress toward goals and reasons why interventions were not provided, and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that employees who perform restorative nursing services receive training on and competency assessment for range of motion.
Closure Date:
15 We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and are signed and dated by a Level 2 magnetic resonance imaging personnel prior to the scan and that compliance be monitored.
Closure Date:
16 We recommended that facility policy be revised to correct contradictory elements and to be consistent with VHA policy.
Closure Date:
17 We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted to determine the risk of tuberculosis transmission to contractors.
Closure Date:
18 We recommended that processes be strengthened to ensure that construction site inspections are conducted at the required frequency and that inspections contain all elements required by VHA policy.
Closure Date:
19 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in Infection Control Committee minutes.
Closure Date:
20 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
Closure Date:
21 We recommended that processes be strengthened to ensure that all construction projects comply with VHA policy requirements.
| ||||
| 14-02100-271 | Inspection of VA Regional Office Portland, Oregon | Review | ||
1 We recommended the Portland VA Regional Office Director implement a plan to ensure staff timely process rating reductions for temporary 100 percent disability evaluations.
Closure Date:
2 We recommended the Portland VA Regional Office Director conduct a review of the 364 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommended the Portland VA Regional Office Director assess the effectiveness of training for special monthly compensation and ancillary benefits claims.
Closure Date:
4 We recommended the Under Secretary for Benefits implement a national plan for an additional level of review for special monthly compensation and ancillary benefits claims.
Closure Date:
5 We recommended the Portland VA Regional Office Director implement a plan, and assess the effectiveness of the plan, to ensure adequate and continuous oversight of completing Systematic Analyses of Operations.
Closure Date:
6 We recommended the Portland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
| ||||
| 14-01688-303 | Inspection of VA Regional Office Salt Lake City, Utah | Review | ||
1 We recommended the Salt Lake City VA Regional Office Director develop and implement a plan to ensure staff take timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommended the Salt Lake City VA Regional Office Director develop and implement a plan to review for accuracy the 135 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommended the Salt Lake City VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
4 We recommended the Salt Lake City VA Regional Office Director amend the local workload management plan to ensure timeliness standards for processing benefits reduction workloads consistent with Veterans Benefits Administration policy.
Closure Date:
| ||||
| 14-00925-299 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the parent facility includes staff at the Northampton County and Williamsport CBOCs in required education, training, planning, and participation in annual disaster exercises.
Closure Date:
2 We recommended that the parent facility documents Emergency Management Preparedness-specific training completed for the Northampton County and Williamsport CBOCs' clinical providers.
Closure Date:
3 We recommended that the parent facility's Emergency Management Committee evaluates the Northampton County and Williamsport CBOCs' emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff consistently document the offer offurther treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
6 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
7 We recommended that staff provide medication counseling/education as required.
Closure Date:
| ||||
| 14-03212-295 | Healthcare Inspection – Emergency Department Concerns, Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas | Hotline Healthcare Inspection | ||
1 We recommended that the Eastern Kansas Health Care System Director ensure that all patients who present to the Eastern Kansas Health Care System Emergency Department requesting an examination or treatment receive a medical screening examination and that compliance is monitored.
Closure Date:
2 We recommended that the Eastern Kansas Health Care System Director ensure Leavenworth VAMC Emergency Department and Primary Care Clinic nursing staff document required assessments and that compliance is monitored.
Closure Date:
| ||||
15303