Date Issued
|
Report Number
16-00577-335
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/15/2017
We recommended that the facility designate a physician anticoagulation program champion.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/29/2018
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
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 that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 1/3/2018
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
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 the training is documented in employee training records.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/29/2018
We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.