Date Issued
|
Report Number
16-00566-314
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Quality, Safety, and Value Committee be consistently chaired or co-chaired by the Facility Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/23/2019
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that facility managers ensure carpets and tile floors in patient care areas are clean and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug-to-drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a Disruptive Behavior Committee/Board.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
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. 14
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
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. 16
to Veterans Health Administration (VHA)
Closure Date: 4/16/2018
We recommended that clinicians enter orders for mammograms in the Computerized Patient Record System and that clinical managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/19/2017
We recommended that clinicians screen patients for tetanus vaccinations at clinic visits and that clinical managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 9/17/2018
We recommended that clinicians document all required vaccine administration elements and that clinical managers monitor compliance.