All Reports

Deficiencies in Administrative Actions for a Patient’s Inpatient Mental Health Unit and Community Living Center Admissions at the Tuscaloosa VA Medical Center in Alabama
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20-02907-254
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The Tuscaloosa VA Medical Center Director reviews informed treatment consent processes for the Inpatient Mental Health Unit and Community Living Center, confirms staff understanding of required processes, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures decision-making capacity evaluation completion and documentation, as required by Veterans Health Administration policy, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2022
The Tuscaloosa VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of Alabama commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures adherence to Tuscaloosa VA Medical Center policies regarding against medical advice discharge procedures, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director consults with VA National Center for Ethics in Healthcare and reconsults the Office of General Counsel as needed to evaluate the appropriateness of the patient’s assigned surrogate decision-maker, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Tuscaloosa VA Medical Center Director ensures staff completion of required patient advocate reporting and tracking processes, and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director evaluates the Community Living Center staff’s management of the patient’s correspondence request, including the Integrated Ethics consultation, and takes action as warranted.
Comprehensive Healthcare Inspection of the Providence VA Medical Center in Rhode Island
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21-00265-231
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2023
The Associate Director for Patient Care evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Mismanagement of a Patient at the Tomah VA Medical Center in Wisconsin
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20-01917-242
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2022
The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2022
The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01502-240
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Deficiencies in the Assessment and Care of a Patient Seeking Geriatric Services at the Fayetteville VA Medical Center in North Carolina
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21-00371-222
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison
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21-00232-205
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas
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20-03635-217
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Topics:  COVID-19 ● Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Comprehensive Healthcare Inspection of the Sheridan VA Medical Center in Wyoming
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21-00255-200
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Deficiencies in the Management of a Patient’s Reported Intimate Partner Violence, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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20-03763-207
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director ensures mental health staff consult with the Intimate Partner Violence Assistance Program and safety plan, as warranted to address Intimate Partner Violence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Ralph H. Johnson VA Medical Center Director ensures Inpatient Mental Health Unit resident physicians complete timely clinical documentation in accordance with Ralph H. Johnson VA Medical Center Policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director makes certain staff consult with the Office of General Counsel to determine reporting requirements of Intimate Partner Violence, as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Under Secretary for Health establishes clear guidance related to Intimate Partner Violence training requirements.
Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon
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20-01259-196
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs evaluate practitioners based on service-specific criteria.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.
Failures in Care Coordination and Reviewing a Patient’s Death at the VA Salt Lake City Healthcare System in Utah
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21-00657-197
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/7/2022
The VA Salt Lake City Healthcare System Director conducts a clinical review of the care provided to the patient on Monday (day 7), by Idaho Falls Community-Based Outpatient Clinic staff, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director reviews the processes involved in conducting root cause analyses to ensure that final reports contain complete and accurate information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director determines if an institutional disclosure is warranted following the completion of the clinical review of this patient’s care and takes action as necessary.
Comprehensive Healthcare Inspection of the VA Puget Sound Health Care System in Seattle, Washington
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20-01261-194
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines the reasons for noncompliance and ensures that improvement actions recommended by the Executive Leadership Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee completes at least eight patient safety analysis processes each fiscal year.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee includes an analysis of underlying systems in all root cause analyses.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that improvement actions identified from root cause analyses are implemented.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines reasons for noncompliance and ensures the Patient Safety Manager or designee provides an annual patient safety report to healthcare system leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document focused professional practice evaluation criteria in practitioner profiles.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that licensed independent practitioners’ professional practice evaluations are completed by providers with similar training and privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that service chiefs’ reprivileging decisions are based on ongoing professional practice evaluation data.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Credentialing and Privileging Committee meeting minutes consistently reflect the review of professional practice evaluation results and the rationale for privileging recommendations.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing for patients prior to initiating long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up evaluations of patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and effectiveness of the interventions.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete goals of care conversations and life-sustaining treatment decisions progress notes.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains the required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees receive monthly continuing education.
Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee
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20-04341-182
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2023
The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures that the Supervisory Audiologist conducts performance appraisals of audiologists in compliance with the Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with Veterans Health Administration’s state licensing board reporting policy, and takes action as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates a review of the audiologist’s conduct to determine whether a report to the state licensing board is indicated, in accordance with the Veterans Health Administration policy.
Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas
|
20-02993-181
|
Topics:  Mental Health ● Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures completion of suicide risk screening and evaluation in accordance with Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff collaboratively develop and update safety plans with patients to reflect the patient’s current risk and protective factors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures adherence to Veterans Health Administration requirements and VA Southern Nevada Healthcare System Standard Operating Procedure 116-14, Suicide Prevention Daily Operations, October 2019, in the consideration of high risk for suicide patient record flags.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director evaluates substance use disorder diagnostic and treatment referral processes for patients on the Inpatient Mental Health Unit and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director reviews current practices to ensure Inpatient Mental Health Unit staff reconcile and incorporate critical clinical information into treatment and discharge planning.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director expedites the establishment of mental health treatment coordinator policy in accordance with Veterans Health Administration requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff coordinate discharge plans with outpatient treatment providers, in accordance with Veterans Health Administration requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures patient complaints and requests are addressed in accordance with Veterans Health Administration requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director promotes leaders’ accurate identification of sentinel events consistent with The Joint Commission definition and Veterans Health Administration requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director conducts a full review of the patient’s care, determines whether an institutional disclosure is warranted, and takes action as indicated.
Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon
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20-01257-180
|
Topics:  Patient Safety ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of aberrant drug-related behaviors prior to initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque
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20-00716-177
|
Topics:  Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia
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20-00354-178
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director confirms that the Chief of the Health Information Management program monitors documentation to include patient care episodes without an associated progress note as part of the ongoing electronic health record review process, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The Charlie Norwood VA Medical Center Director ensures a policy defines the required time frame for providers to respond to view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director continues to monitor providers’ compliance with responding to view alerts, evaluates the effectiveness of the implemented strategies to reduce unnecessary view alerts, and assesses the need for retrospective reviews of patient care related to accumulated view alerts.
Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
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19-09808-171
|
Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens
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20-02968-170
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida
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20-03535-146
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
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