Date Issued
|
Report Number
14-02071-02
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
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.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
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.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/9/2015
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.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
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.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
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.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
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.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 2/20/2015
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.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 10/14/2014
We recommended that facility policy be revised to correct contradictory elements and to be consistent with VHA policy.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 9/29/2015
We recommended that processes be strengthened to ensure that tuberculosis risk assessments are conducted to determine the risk of tuberculosis transmission to contractors.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 7/10/2015
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.
No. 21
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all construction projects comply with VHA policy requirements.