Date Issued
|
Report Number
15-00069-199
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that when conversions from observation bed status to acute admissions are 25–30 percent or more, the facility reassess observation criteria and utilization.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the Surgical Work Group include the Chief of Staff as a member.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the Safe Patient Handling Committee track patient handling injury data.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended the facility ensure a third party conducts quality assurance reviews on a sample of the scanned documents.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Environment of Care Board and Safety Committee minutes include corrective actions to address identified deficiencies and track those actions to closure.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure community living center treatment carts containing resident care supplies are clean and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure critical medical equipment in the community living center is plugged into outlets that function in the event of a power loss and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and minimum competency requirements for users and that facility managers monitor compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that nursing reviewers sign the monthly medication review forms and that facility managers monitor compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the facility’s recently chartered Consult Management Committee meet regularly and document oversight of consult management.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that consultants do not change the consult request status for inappropriate reasons and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that Level 2 magnetic resonance imaging personnel review and sign secondary patient safety screening forms prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 5/24/2016
We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required elements and that facility managers monitor compliance.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 12/8/2015
We recommended that facility managers ensure the American Lake division follows local emergency airway management policy, or if the facility plans to perform intubations in areas designated to call 911, the facility updates the local emergency airway management policy and ensures privileged providers or clinicians with emergency airway management scope of practice are available.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 2/18/2016
We recommended that facility managers ensure reporting of emergency airway management data to the designated committee with the frequency required by local policy.