Breadcrumb

Combined Assessment Program Review of the Bay Pines VA Healthcare System, Bay Pines, Florida

Report Information

Issue Date
Report Number
14-01292-258
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a review 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 204 employees. This review focused on seven operational activities. The facility complied with selected standards in the following two activities (1) medication management and (2) magnetic resonance imaging safety. The facility’s reported accomplishments were receiving the VA National Center for Patient Safety Gold Cornerstone Award and being named as a Top Performer on Key Quality Measures® by The Joint Commission. OIG made recommendations for improvement in the following five activities: (1) quality management, (2) environment of care, (3) coordination of care, (4) acute ischemic stroke care, and (5) community living center resident independence and dignity.

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 the review of electronic health record quality includes most services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that the Blood Usage Review Committee member from Surgery Service consistently attends meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that community living center doors are secured after hours 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 crash carts inspections on the dialysis and locked mental health units include the defibrillators and are documented 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 all designated same day surgery and post-anesthesia care unit employees receive bloodborne pathogens training annually 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 designated eye clinic employees receive eye laser safety training every 2 years 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 clinicians identify post-discharge needs and include them in discharge planning.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that clinicians provide individualized, patient-specific discharge instructions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that stroke guidelines be posted on the medical intensive care; 5B medical; and east, central, and west CLC units.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
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.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all care planned/ordered assistive eating devices are provided to residents for use during meals.