Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas

Report Information

Issue Date
Report Number
14-02080-29
VISN
State
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
3
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 73 employees. This review focused on seven operational activities. The facility complied with selected standards in the following five activities: (1) quality management, (2) environment of care, (3) medication management – controlled substances inspection program, (4) continuity of care, and (5) Mental Health Residential Rehabilitation Treatment Program. The facility’s reported accomplishments were Click 2 Benefits and the Get Well Network. OIG made recommendations for improvement in the following two activities (1) community living center resident independence and dignity and (2) management of test results.

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 staff document monthly restorative nursing services progress notes in residents’ electronic health records and that compliance be monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that residents are offered transfer from their wheelchairs to regular dining chairs during meal periods.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health record.