Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky

Report Information

Issue Date
Report Number
15-00619-515
VISN
State
Kentucky
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 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 255 employees. This review focused on eight operational activities. The facility complied with selected standards in the following four activities: (1) medication management, (2) coordination of care, (3) computed tomography radiation monitoring, and (4) surgical complexity. The facility’s reported accomplishments were the lung nodule evaluation team and the Women’s Health Program. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) environment of care, (3) advance directives, and (4) emergency airway management.

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 facility managers ensure that licensed practitioners who perform emergency airway management have the appropriate training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Surgical Work Group meet monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure negative air pressure systems in the medicine primary care clinic are functional and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure locked mental health unit stationary panic alarm testing includes documentation of VA Police response time.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that equipment on the locked mental health unit is secured and heavy enough to prevent it from being picked up, thrown, moved, or overturned.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required subject matter content elements and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the local policy for out of operating room emergency airway management to include successful demonstration of all required procedural skills on airway simulators for providers seeking renewal of privileges.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility document the review of provider-specific emergency airway management data in Cardiopulmonary Review Committee meeting minutes.