Date Issued
|
Report Number
16-00548-361
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that facility managers ensure all fire extinguishers are inspected monthly and marked with the correct date and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/29/2019
We recommended that employees document when they access information technology network rooms by using the visitor logs and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/16/2018
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive annual competencies for the types of reusable medical equipment they reprocess.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that hemodialysis unit employees wear gloves when handling patient equipment and that the hemodialysis unit manager monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating warfarin treatment.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in the competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/16/2018
We recommended that the facility collect and report data on patient transfers out of the facility and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and of medical and behavioral stability in transfer documentation and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/8/2019
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that the facility update its policy on the community nursing home program to include all elements required by Veterans Health Administration policy.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that a VA physician order or approve all therapies that are at VA expense.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 5/8/2018
We recommended that facility managers ensure the community nursing home program office scans existing paper health records into electronic health records and develops a process to scan new records as they are received.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that the facility update its policy on preventing and managing disruptive and violent behavior.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that the VA Police Officer and the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 3/14/2018
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that training is documented in employee training records.