Recommendations
817
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00271-265 | Healthcare Inspection – Emergency Department Staffing and Patient Safety Issues, VA San Diego Healthcare System, San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director implement a policy that includes a plan for additional registered nurses, providers, and support staff to augment the Emergency Department in times of acute overload or disaster.
Closure Date:
2 We recommended that the System Director review the orientation processes for registered nurses floating to the Emergency Department to ensure that the orientation provided is adequate and documented consistently.
Closure Date:
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| 14-02068-264 | Combined Assessment Program Review of the Grand Junction VA Medical Center, Grand Junction, Colorado | Comprehensive Healthcare Inspection Program | ||
| 14-02066-266 | Combined Assessment Program Review of the Providence VA Medical Center, Providence, Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that completed actions from peer reviews are reported to the Peer Review Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Special Care Committee collects data that measures performance in responding to codes.
Closure Date:
3 We recommended that the Surgical Service Staff Committee meet monthly.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee meets at least quarterly and that the blood/transfusions usage review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
5 We recommended that processes be strengthened to ensure that when data analysis indicates problems or opportunities for improvement, actions are consistently identified, implemented, and followed to resolution in surgical performance improvement activities, electronic health record quality reviews, and blood/transfusion reviews.
Closure Date:
6 We recommended that processes be strengthened to ensure that all patient care areas and public restrooms are clean and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that procedures for terminal cleaning of patient rooms are followed and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that in patient care areas, damaged furniture is repaired or removed from service and damaged surfaces are repaired and that compliance be monitored.
Closure Date:
9 We recommended that the pharmacy clean room for compounding sterile products be brought into compliance with United States Pharmacopeia 797> cleanliness, sterility, and monitoring standards.
Closure Date:
10 We recommended that processes be strengthened to ensure that all required members of the Environment of Care Committee consistently attend committee meetings, that the program be strengthened to ensure effective surveillance activities, and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that VA Police update the facility’s Security Management Plan annually and submit quarterly security reports to the Environment of Care Committee.
Closure Date:
12 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that clinician assessment of patients presenting with stroke symptoms includes facility required PTT and PT/INR tests and that compliance be monitored.
Closure Date:
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| 13-00670-262 | Healthcare Inspection - Follow-up Review of the Pause in Providing Inpatient Care VA Northern Indiana Healthcare System, Fort Wayne, Indiana | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure continued monitoring and implementation of actions for the reopening of the Intensive Care Unit.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that efforts continue to recruit qualified clinical staff to provide care.
Closure Date:
3 We recommended that the VA Northern Indiana Healthcare System Director ensure that efforts continue to recruit qualified staff for vacant leadership positions.
Closure Date:
4 We recommended that the VA Northern Indiana Healthcare System Director ensure that nursing leaders assess the utilization of the nursing staff to systemically plan assignments during times when the acute medical unit¿s census is low.
Closure Date:
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| 14-01292-258 | Combined Assessment Program Review of the Bay Pines VA Healthcare System, Bay Pines, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the review of electronic health record quality includes most services.
Closure Date:
2 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Surgery Service consistently attends meetings.
Closure Date:
3 We recommended that processes be strengthened to ensure that oxygen tanks on the 3C surgical, 5B medical, and the 4A telemetry units are stored in a manner that distinguishes between empty and full tanks and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that soiled utility rooms on the 5A medical, east and central community living center, and medical and surgical intensive care units are locked and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that community living center doors are secured after hours and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure crash carts inspections on the dialysis and locked mental health units include the defibrillators and are documented and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that all designated same day surgery and post-anesthesia care unit employees receive bloodborne pathogens training annually and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that all designated eye clinic employees receive eye laser safety training every 2 years and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians identify post-discharge needs and include them in discharge planning.
Closure Date:
10 We recommended that processes be strengthened to ensure that clinicians provide individualized, patient-specific discharge instructions.
Closure Date:
11 We recommended that stroke guidelines be posted on the medical intensive care; 5B medical; and east, central, and west CLC units.
Closure Date:
12 We recommended that the facility report to VHA the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff consistently complete and document restorative nursing services according to clinician orders and/or residents¿ care plans and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.
Closure Date:
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| 14-02603-267 | Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System | Audit | ||
| 14-00657-261 | Audit of VBA's Efforts to Effectively Obtain Veterans' Service Treatment Records | Audit | ||
| 14-00991-255 | Healthcare Inspection – Deficiencies in the Caregiver Support Program, Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
| 14-02067-253 | Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
2 We recommended that the Surgical Work Group continue to meet monthly and document its review of required performance data elements and National Surgical Office reports.
3 We recommended that processes be strengthened to ensure that all surgical deaths with identified problems or opportunities for improvement are reviewed by the Surgical Work Group.
4 We recommended that processes be strengthened to ensure that the Blood Usage Review Committee representative from Surgical Service consistently attends meetings and that the blood/transfusions usage review process includes the results of proficiency testing and the results of inspections by government or private (peer) entities.
5 We recommended that processes be strengthened to ensure that Environment of Care Committee minutes reflect discussion of actions taken in response to identified deficiencies and that actions are tracked to closure.
6 We recommended that processes be strengthened to ensure that expired medications are promptly removed from patient care areas and that compliance be monitored.
7 We recommended that the facility’s stroke policy be revised to
address data gathering for analysis and improvement and that compliance be
monitored.
8 We recommended that processes be strengthened to ensure that
clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
9 We recommended that stroke guidelines be posted on the critical care unit and the acute inpatient unit.
10 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
11 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
12 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans and that compliance be monitored.
13 We recommended that processes be strengthened to ensure that secondary patient safety screenings are completed immediately prior to magnetic resonance imaging and that compliance be monitored.
14 We recommended that processes be strengthened to ensure that secondary patient safety screening forms are signed by the patient, family member, or caregiver and that compliance be monitored.
15 We recommended that processes be strengthened to ensure 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 compliance be monitored.
16 We recommended that processes be strengthened to ensure that all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that construction site inspection documentation includes the time of the inspection, the team members present, and the time when corrective actions occurred.
18 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of unsafe conditions identified during inspections and follow-up actions in response to those conditions and that minutes track actions to completion.
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| 14-00924-247 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that the installed modification alarm works consistently so that staff can be notified when veterans require assistance for entry into the Hamlet CBOC.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
4 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed Fluoroquinolones was administered, prescribed, or modified.
Closure Date:
5 We recommended that staff consistently provide written medication information that includes the Fluoroquinolones.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
Closure Date:
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11259