All Reports

We recommended that the Facility Director ensure that Community Living Center staff have competency assessments and validations completed for care of residents with suprapubic catheters, including catheter insertion and irrigation.

We recommended that the Facility Director strengthen processes to ensure that Community Living Center staff carry out physician orders for bladder irrigation and monitor compliance.

We recommended that the Facility Director strengthen processes to ensure that Community Living Center staff conduct and document resident checks for well-being, skin assessments, and activities of daily living assistance as required and monitor compliance.

We recommended that the Facility Director strengthen processes to ensure that procedures are followed for obtaining special care beds and mattresses.

We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that for employees who prepare compounded sterile products, facilities include in their competency assessment requirements gloved fingertip sampling and the required number of gloved fingertip samplings for initial competency assessment.

We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities include in the competency assessment checklists of employees who prepare compounded sterile products donning of personal protective equipment in the required order and performance of appropriate hand hygiene after personal protective equipment removal.

We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure competency assessments for employees who prepare compounded sterile products include gloved fingertip sampling, written tests, and visual observation or “hands-on” skill assessment of aseptic technique at the required risk level frequency.

We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure sterile chemotherapy-type gloves are available in areas where hazardous compounded sterile products are prepared.

We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure employees clean sterile compounding area floors daily and storage shelving monthly and document the cleaning.

We recommended that the Facility Director ensure that providers assign the proper inpatient/outpatient setting and urgency of consults in the electronic health record.

We recommended that the Facility Director ensure that staff take action within 7 days of a consult request or sooner if clinically indicated.

We recommended that the Facility Director ensure that staff timely close or discontinue consults.

We recommended that the Facility Director ensure that staff conduct a review on the quality and timeliness of the cardiology care for Patient 1 as discussed in the report, and take action if appropriate.

We recommended that the Facility Director ensure that staff monitor and address the care needs of patients on the Homemaker/Home Health Aide services electronic wait list.

We recommended that the Facility Director ensure that clean and dirty patient care equipment items are stored separately in the Community Living Center, that managers monitor compliance, and that monitors include shower litters and wheelchairs as specific items.

We recommended that the Facility Director ensure that program staff coordinate mental health appointments, including verifying the necessity, between facility providers and assigned community nursing home physicians prior to scheduling.

We recommended that the Facility Director ensure clinical staff report suspected elder abuse within the required timeframe and document the reporting in the patient’s electronic health record.

We recommended that the Facility Director ensure Non-VA Care Coordination staff timely deliver authorizations for consulted services to contracted community nursing home staff and that facility scheduling staff recognize when patients reside in a community nursing home and coordinate appointments with program or contracted community nursing home staff to ensure timely response to consults.

We recommended that the Facility Director require program registered nurses and social workers consistently conduct monthly or quarterly follow-up visits and ensure timely resolution of patient care needs identified in these visits.