Date Issued
|
Report Number
13-02316-322
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/22/2014
We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/19/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 2/19/2014
We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 6/17/2014
We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 2/18/2014
We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.