Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky

Report Information

Issue Date
Report Number
13-03652-59
VISN
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
10
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 286 employees. This review focused on seven operational activities. The facility complied with selected standards in the following five activities: (1) medication management, (2) coordination of care, (3) nurse staffing, (4) pressure ulcer prevention and management, and (5) community living center resident independence and dignity. The facility’s reported accomplishment was increasing the availability and timeliness of scanned documents in the electronic health record. OIG made recommendations for improvement in the following two activities (1) quality management and (2) environment of care.

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)
We recommended that processes be strengthened to ensure that all surgical deaths are reviewed by the facility's Surgical Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the critical incident tracking and notification system's recipient list is current.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that that processes be strengthened to ensure that the Transfusion and Tissue Review Committee member from Anesthesia Service consistently attends meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that that processes be strengthened to ensure that the CRC meets monthly and includes physician participation.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that EOC Committee minutes reflect deficiencies identified on the locked MH unit and that MH Risk Assessment and Abatement Tracking data reflect risk levels and tracking of actions to closure for all identified environmental hazards on the locked MH unit.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that access to emergency exits at the Cooper division is unrestricted and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that chemicals stored on the hemodialysis unit are secured at all times and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all MSIT members and occasional locked MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA's National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all panic alarms on the locked MH unit are routinely tested and that compliance be monitored.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all audiovisual equipment on the locked MH unit is properly secured.