Date Issued
|
Report Number
15-04707-111
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility manager’s monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Patient Safety Manager provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, include corrective actions to address those deficiencies, and track corrective actions to closure.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that Hospital Epidemiology Committee meeting minutes consistently reflect discussion of identified high-risk areas and implementation of actions to address those areas and document follow-up on actions implemented to address identified problems.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise operating room emergency fire policy and procedures to include alarm activation, evacuation, and equipment shutdown with responsibility for turning off room or zone oxygen.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes visual observation/“hands-on” skill assessment of aseptic technique and gloved fingertip sampling.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers ensure all hoods are certified at least every 6 months and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that special care unit sending nurses document transfer assessments and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended physicians consistently document discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that facility managers review the organizational alignment for the Radiation Safety Officer position to ensure compliance with Veterans Health Administration policy.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that facility managers develop and implement a comprehensive computed tomography policy that includes a quality control program and procedures to follow when revising computed tomography protocols.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that computed tomography technologists perform and document quality control checks, that a supervisory employee conducts periodic review to verify the checks were done, and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 12/9/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 9/26/2016
We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.