Date Issued
|
Report Number
16-00579-293
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, corrective actions taken to address identified deficiencies, and tracking of corrective actions to closure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility implement actions to address all high-risk areas and ensure Infection Control Committee minutes document those actions and the follow-up on actions implemented to address identified problems.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that the facility review quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure that clinicians consistently obtain all required laboratory tests prior to initiating anticoagulation warfarin treatment and that clinicians obtain initial prothrombin/international normalized ratio through laboratory testing.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
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. 9
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility managers ensure that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility¿s capacity and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
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. 18
to Veterans Health Administration (VHA)
Closure Date: 12/7/2017
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags and ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 4/4/2018
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. 20
to Veterans Health Administration (VHA)
Closure Date: 10/12/2018
We recommended that clinicians provide education and counseling to patients with positive alcohol screens and who reported drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.