Date Issued
|
Report Number
16-00572-179
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, the specific deficiencies, corrective actions taken to address identified deficiencies, and resolutions.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure attendance is documented for all fire drills.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure fire drills have documented critiques.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that facility managers ensure eye protection equipment is readily available for employees.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that facility managers ensure standard operating procedures for the colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with manufacturer instructions for use.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/28/2017
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training at orientation for the types of reusable medical equipment they reprocess.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility consistently review and report all quality assurance data measures for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the facility monitor and evaluate patient transfers as part of the quality management program.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Chief of Pathology and Laboratory Medicine Service ensure employees who perform point-of-care glucose testing comply with facility policy for managing critical glucose values.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that providers include history of previous adverse experience with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts using a checklist prior to moderate sedation procedures and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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 and monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 11/21/2017
We recommended that the Patient Safety Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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. 20
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
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.