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Healthcare Inspection – Alleged Lapse in Timeliness of Care, West Palm Beach VA Medical Center, West Palm Beach, Florida

Report Information

Issue Date
Report Number
15-00191-406
VISN
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to allegations about the lack of timeliness of care and management action at the West Palm Beach VA Medical Center (facility), West Palm Beach, FL. We substantiated the allegation that the patient was not on the schedule for an interventional radiology (IR) procedure; however, the patient was brought to the IR area for insertion of a peripherally inserted central catheter line (a non-IR procedure). We substantiated that the patient was transported from the Emergency Department (ED) to the IR area without being appropriately monitored and was not placed on a monitor immediately on arrival to the IR area. In addition, we found that required communication between nursing staff in the ED and the IR nurse did not take place prior to the patient being transported from the ED to the IR area. We also found that the facility policy for handoff communication does not describe how handoff communication is to be documented. We did not substantiate that cardiopulmonary resuscitation (CPR) was not begun promptly when a “code” was called. Our review of the patient’s electronic health record found that when the patient was recognized to be in distress, resuscitation efforts took place quickly. We did not substantiate the allegation that management was notified of CPR timeliness concerns but failed to take proper action. We recommended that the Facility Director ensure that unstable patients be appropriately monitored during transport from one location to another. We also recommended that the Facility Director ensure that ED and IR nursing staff receive education in handoff communication requirements and that the facility policy for handoff communications be reviewed for inclusion of documentation of handoff communication. The Veterans Integrated Service Network and Facility Directors agreed with our findings and recommendations and provided acceptable improvement plans.

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 the Facility Director implement procedures to ensure that unstable patients being transported from one area to another in the facility be monitored safely and accompanied by appropriate personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that Emergency Department and Interventional Radiology nursing staff receive education on handoff communication requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the facility policy for the handoff communication process be reviewed for inclusion of documentation of handoff communication.