All Reports

The Phoenix VA Health Care System Director ensures that providers are educated on conducting clinical disclosures and documenting the discussion in the patient’s electronic health record when harm is determined to be more than minor.

The Phoenix VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, and ensures the current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.

The Phoenix VA Health Care System Director confirms that the Peer Review Committee record formal discussions in meeting minutes, including discussion specific to changes in rating levels in accordance with Veterans Health Administration policy, and monitors compliance.

The Phoenix VA Health Care System Director makes certain adverse events or close calls are entered into the Joint Patient Safety Reporting system and the facility patient safety manager completes reviews, assigns a safety assessment code score, and conducts root cause analyses in accordance with Veterans Health Administration policy, and monitors compliance.

The Phoenix VA Health Care System Director evaluates the process for the communication of abnormal test results to patients and ensures that ordering providers or designees provide timely notification to patients in a manner that informs patients of the results in accordance with Veterans Health Administration policy, and monitors compliance.

The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.

The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.

The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.

The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.

The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.

The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.

The Director evaluates and determines additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures electrical receptacles and switches in the mental health unit are covered by metal plates, secured by tamper-resistant screws, and receptacles are flush to the wall.

The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.

The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.

The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.

The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.

The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.

The West Texas VA Health Care System Director ensures that community living center nursing staff are trained on their roles, responsibilities, and necessary actions when responding to a medical emergency.

The West Texas VA Health Care System Director certifies that mock codes are completed within the community living center at regular intervals and include all community living center nursing staff.

The West Texas VA Health Care System Director ensures that documentation requirements are met by community living center clinical staff and monitors compliance.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Leadership Board recommends, implements, and monitors improvement actions.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff either conduct an individual root cause analysis for all events receiving an actual or potential safety assessment code score of three or include the events in an aggregated review.

The Chief of Staff determines the reasons for noncompliance and ensures providers with similar training and privileges complete licensed independent practitioners’ Focused Professional Practice Evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend licensed independent practitioners’ continued privileges based on Ongoing Professional Practice Evaluation activities.

The Associate Director and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff remove supplies from shipping cartons and corrugated boxes prior to putting them in clean storage areas.

The Director determines the reasons for noncompliance and ensures leaders evaluate adverse events and conduct institutional disclosures when criteria are met.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider service-specific Ongoing Professional Practice Evaluation data when recommending licensed independent practitioners’ continued privileges.

The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for reprivileging decisions.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluations completed by practitioners with similar training and privileges.

The Charlie Norwood VA Medical Center Director ensures primary care teams adhere to Veterans Health Administration policies related to mental health screenings, consult management, and care coordination, and monitors compliance.

The Charlie Norwood VA Medical Center Director develops a process to ensure that Emergency Department staff communicate patients’ referral information from the Veterans Crisis Line to Emergency Department providers.

The Charlie Norwood VA Medical Center Director ensures that suicide prevention staff documentation is complete and accurate, and actions are taken to resolve issues identified in Veterans Crisis Line referrals prior to closure.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.

The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.

The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.

The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.

The Veterans Integrated Service Network Director evaluates the role of the Patient Safety/ Risk Management Subcommittee to determine the degree to which the subcommittee will address facility level performance with Patient Safety Program activities and tracking of action plans when a deficiency is identified, and updates the subcommittee charter as warranted.

The Under Secretary for Health evaluates the process for programmatic oversight by VA’s National Center for Patient Safety over Veterans Integrated Service Networks’ and facilities’ patient safety programs.

The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.

The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.

The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.