All Reports

Date Issued
|
Report Number
21-00290-116
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Director evaluates and determines the reasons for noncompliance and makes certain that leaders accurately identify and report adverse events as sentinel events when criteria are met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Surgical Work Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/9/2022
The Chief of Staff and Associate Director for Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2023
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
Date Issued
|
Report Number
21-00282-111
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all sentinel events.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Medical Center Director determines the reasons for noncompliance and ensures the Systems Redesign Manager participates on the Veterans Integrated Service Network Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/17/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members regularly attend Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/6/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training.

Date Issued
|
Report Number
21-00656-110
|
Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 4/9/2024

The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.

No. 2
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.

Date Issued
|
Report Number
21-00781-109
|
Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/2/2023

The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.

Date Issued
|
Report Number
21-00781-108
|
Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/3/2023

The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/19/2022

The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.

Date Issued
|
Report Number
21-00281-100
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2023
The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2023

The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.

Date Issued
|
Report Number
21-00280-89
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Date Issued
|
Report Number
21-00289-90
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits a quarterly summary analysis for review by the Medical Executive Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Facility Surgical Workgroup reviews surgical deaths and evaluates critical surgical events as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2022
The Chief of Staff and Nurse Executive (ADPCS/Chief Nurse Executive) evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-02492-77
|
Topics:  Care Coordination ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The VA Eastern Colorado Health Care System Director reviews the transition in care process for patients transferring between primary care providers to ensure continuous care that facilitates communication and avoids missed opportunities, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The VA Eastern Colorado Health Care System Director ensures that providers develop and update patient problem lists as required and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The VA Eastern Colorado Health Care System Director ensures that primary care providers are educated on the expectations of reviewing a patient’s electronic health record when assuming care of an established patient.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient’s care by the primary care providers, determines if an adverse event occurred, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2022
The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient identified during the inspection who did not receive hepatocellular carcinoma surveillance or varices monitoring, determines if an adverse event occurred, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2023
The VA Eastern Colorado Health Care System Director ensures that patients requiring hepatocellular carcinoma surveillance and varices monitoring receive the recommended imaging studies, lab tests, and esophagogastroduodenoscopies, and monitors compliance.
Date Issued
|
Report Number
21-01507-61
|
Topics:  Patient Safety ● Mental Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.

Date Issued
|
Report Number
21-01038-49
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews primary care and pulmonology processes to ensure patients with high-risk factors for lung cancer receive screening and follow-up care and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
The VA Southern Nevada Healthcare System Medical Center Director implements processes to ensure that patients with abnormal radiology findings have appropriate follow-up and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The VA Southern Nevada Healthcare System Medical Center Director ensures that providers follow the guidelines for surveillance for patients who have undergone prostatectomy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Director reviews primary care providers’ copy and paste practices, implements processes to ensure a current plan of care is documented in the electronic health record, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews the complaint reporting and responding processes, ensures complaints are addressed in accordance with Veterans Health Administration policy, and monitors compliance.
Date Issued
|
Report Number
21-01801-45
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Eastern Oklahoma VA Health Care System Facility Director reviews processes to ensure patients with ordered Fecal Immunochemical Test (FIT) are tracked according to Veterans Health Administration policy, documentation is complete, and takes action if necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director evaluates processes for Emergency Department providers’ physical examinations when a patient presents with gastrointestinal symptoms that include associated bleeding and determines if modifications, including provider education, are needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2022
The Eastern Oklahoma VA Health Care System Facility Director ensures that patient advocates and Primary Care leaders perform thorough reviews of all components of complaints for resolution and patient advocates document according to policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director ensures facility leaders monitor complaints and take action on issues that are identified related to the Emergency Department physician’s performance.
Date Issued
|
Report Number
21-01049-39
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
The West Palm Beach VA Medical Center Director evaluates clinical disclosure practices and takes action as warranted to ensure compliance with Veterans Health Administration Directive 1004.08.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director ensures that Patient A’s and Patient B’s episodes of care are reviewed to determine if an institutional disclosure is needed per Veterans Health Administration Directive 1004.08 and takes action accordingly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director evaluates facility compliance with Veterans Health Administration Directive 1004.08 regarding institutional disclosure processes and takes corrective actions as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director explores reasons Joint Patient Safety Reports were not entered for some adverse events experienced by Patient A and Patient B and takes action accordingly to ensure compliance with Veterans Health Administration Handbook 1050.01.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director confirms that the Surgical Workgroup’s meeting minutes document oversight of the Surgical Service Morbidity and Mortality Conference by including issues discussed, conclusions, actions, recommendations, evaluations, and follow up in accordance with Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director identifies reasons a planned peer review was not completed in accordance with Veterans Health Administration Directive 1190 and takes corrective action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director reviews processes for evaluation of urologists’ privileging forms and takes action as necessary to ensure compliance with Veterans Health Administration Handbook 1100.19 and Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
Date Issued
|
Report Number
21-01695-38
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
Date Issued
|
Report Number
20-03700-35
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2022
The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2024

The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2023
The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
Date Issued
|
Report Number
21-01682-25
|
Topics:  Mental Health ● Care Coordination ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2023
The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans Health Administration transportation directives, including management of the transport of residents with behavioral flags.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
Date Issued
|
Report Number
21-00274-289
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Date Issued
|
Report Number
21-00553-285
|
Topics:  COVID-19 ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022
The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Date Issued
|
Report Number
21-01304-275
|
Topics:  COVID-19 ● Patient Safety ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2025

The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.