Date Issued
|
Report Number
16-00569-253
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that facility clinical managers ensure peer reviewers consistently document their evaluation of at least one of the important aspects of care and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
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. 4
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/1/2018
We recommended that facility managers ensure information technology network room logs for visitors contain all required information to document access and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/1/2018
We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that facility managers ensure ice machines in patient nourishment kitchens are clean and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility develop and implement a policy that addresses anticoagulation management.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility designate a physician anticoagulation program champion.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that providers complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 10/1/2018
We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that the Patient Safety Manager and/or Risk Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/20/2017
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. 19
to Veterans Health Administration (VHA)
Closure Date: 5/1/2018
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. 20
to Veterans Health Administration (VHA)
Closure Date: 2/7/2018
We recommended that facility clinical managers ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 7/26/2018
We recommended that employees consistently complete diagnostic assessments for patients with a positive alcohol screen and that facility managers monitor compliance.