Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida

Report Information

Issue Date
Report Number
22-04014-130
VISN
8
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Bay Pines VA Healthcare System, which includes the C.W. Bill Young VA Medical Center and eight outpatient clinics in Florida. This evaluation focused on five key operational areas:
•    Leadership and organizational risks
•    Quality, safety, and value
•    Medical staff privileging
•    Environment of care
•    Mental health (suicide prevention initiatives)

The OIG issued eight recommendations for improvement in four areas:
1.    Leadership and organizational risks
•    Institutional disclosures for sentinel events

2.    Quality, safety, and value
•    Root cause analysis for patient safety events

3.    Environment of care
•    Clean and orderly patient care areas
•    Furnishings and walls in good repair
•    Solid bottom shelves in storage areas
•    Medical equipment inspection, testing, and maintenance 
•    Mental health inpatient unit panic alarm testing

4.    Mental health
•    Monthly reporting of suicide events to quality management staff
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures leaders conduct institutional disclosures for applicable sentinel events.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)

The Director ensures staff complete a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures Environmental Management Service staff keep areas used by patients clean and orderly.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff keep furnishings and walls in good repair.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff use solid bottom shelves in storage areas.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff inspect, test, and maintain medical equipment.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Associate Director ensures staff document VA police response times for panic alarm testing in the mental health inpatient unit.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.