Breadcrumb

Healthcare Facility Inspection of the VA Western Colorado Healthcare System in Grand Junction

Report Information

Issue Date
Report Number
24-00595-93
VISN
State
Colorado
Utah
Wyoming
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Maintenance and Construction
PACT Act
Patient Care Services Operations
Patient Safety
Supplies and Equipment
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) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Western Colorado Healthcare System in Grand Junction. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued eight recommendations for improvement in two domains:
  1.    Environment of care
   •    Toxic exposure screenings
   •    Fire extinguisher inspections
   •    Preventive maintenance inspections 
   •    Wheelchair disinfection, ceiling vent dust removal, and wall repair
   •    Equipment and supply access and storage 
   •    Video monitoring
   •    Veterans Integrated Service Network oversight of the environment of care program
  2.    Patient Safety
   •    Patient test result notification process

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

The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.

No. 2
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to Veterans Health Administration (VHA)

The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.

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

The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.

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

The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.

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

The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.

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

The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.

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

The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.

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

The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.