Date Issued
|
Report Number
10-01388-275
All Reports
Date Issued
|
Report Number
09-00313-273
Date Issued
|
Report Number
05-03285-225
Date Issued
|
Report Number
06-01512-224
Date Issued
|
Report Number
10-00126-230
Date Issued
|
Report Number
10-00689-231
Date Issued
|
Report Number
11-00446-234
Date Issued
|
Report Number
09-03665-232
Date Issued
|
Report Number
10-02487-235
Date Issued
|
Report Number
10-03888-240
Date Issued
|
Report Number
11-00374-239
Date Issued
|
Report Number
11-00057-238
Date Issued
|
Report Number
11-01082-237
Date Issued
|
Report Number
11-01499-236
Date Issued
|
Report Number
09-01858-233
Date Issued
|
Report Number
11-01057-241
Date Issued
|
Report Number
11-01025-242
Date Issued
|
Report Number
15-00347-154
Date Issued
|
Report Number
15-00030-202
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the Medical Executive Committee review privilege forms annually and document the review.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility secure sterile supply cabinets when not in use and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility promptly remove outdated commercial supplies from examination rooms and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure employees lock computers and secure sensitive patient information when they leave the area and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that the facility collect and report to the Veterans Health Administration 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.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 10/8/2015
We recommended that facility managers ensure that intensive care unit, Emergency Department, and medical/surgical unit (4A) employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed and documented for employees on the intensive care unit.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor competency.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 1/4/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and includes all required elements and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the facility correct the identified deficiencies in the domiciliary and that documentation reflect correction.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/28/2015
We recommended that domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
Date Issued
|
Report Number
15-00121-201
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that a functional panic alarm system is installed at the Jay CBOC.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/13/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/20/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.