Date Issued
|
Report Number
16-00558-311
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/16/2018
We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the facility establish a Community Nursing Home Oversight Committee.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/27/2017
We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that facility managers ensure all employees receive 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. 13
to Veterans Health Administration (VHA)
Closure Date: 8/7/2017
We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.