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Combined Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan

Report Information

Issue Date
Report Number
14-00686-166
VISN
State
Michigan
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 93 employees. This review focused on seven operational activities and follow-up on recommendations from the previous Combined Assessment Program review. The facility complied with selected standards in the following four activities: (1) quality management, (2) environment of care, (3) medication management, and (4) coordination of care. The facility’s reported accomplishment was being recognized by Hospitals and Health Networks magazine as one of the Most Wired health care systems in the country. OIG made recommendations for improvement in the following three activities: (1) nurse staffing, (2) pressure ulcer prevention and management, and (3) community living center resident independence and dignity and made repeat recommendations regarding Sterile Processing Service sterile storage humidity levels and environment of care rounds attendance.

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 nursing managers fully implement the plan approved in March 2014.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the annual staffing plan reassessment process ensures that the acute care unit-based expert panel includes all required members.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff accurately document the risk scale score for all patients with pressure ulcers and that compliance be monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that wound care specialist consults are initiated and completed for all patients with pressure ulcers 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 staff complete and document restorative nursing services according to residents' care plans 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 staff document residents' progress toward restorative nursing goals 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 staff document residents' restorative progress bi-weekly 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 required participants or their designees attend weekly EOC rounds and that compliance be monitored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.