Date Issued
|
Report Number
16-00121-320
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/7/2017
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: 1/12/2017
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: 7/29/2017
We recommended that the facility revise the policy and protocol for the identification of individuals entering the facility to include specialty/restricted areas and instructions regarding visitors who enter the facility during business hours and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that facility managers ensure an emergency eyewash station is readily accessible to the chemotherapy compounding area where employees compound hazardous medications.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees wear personal protective equipment and gloves when compounding sterile products in the operating room satellite pharmacy and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that sending nurses document transfer assessments and receiving nurses document transfer notes and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/20/2017
We recommended that attending physicians co-sign resident physicians’ discharge notes/instructions and that facility managers monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that the facility review and revise its advance directives policy to ensure it is consistent with Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that the facility implement a plan for transition to the allowed note titles and that facility managers monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees consistently use appropriate note titles to document screening and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 11/4/2016
We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 1/12/2017
We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that plans include contact numbers of family or friends for support and assessment of available lethal means and how to keep the environment safe and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 4/13/2017
We recommended that clinicians perform and document patient assessments following blood product transfusions and that facility managers monitor compliance.