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Combined Assessment Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas

Report Information

Issue Date
Report Number
15-00622-06
VISN
State
Arkansas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
16
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 344 employees. This review focused on eight operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the surgical complexity activity. OIG made recommendations for improvement in the following activities and follow-up review area: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) computed tomography radiation monitoring, (6) advance directives, (7) emergency airway management, and (8) follow-up on quality 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 the Cardiopulmonary Resuscitation Subcommittee review each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Operating Room Management Council meet monthly, include the Chief of Staff and Surgical Quality Nurse as members, and document its review of National Surgical Office reports.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Operating Room Management Council review all surgical deaths with identified problems or opportunities for improvement.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Infection Prevention and Control Sub-Committee document follow-up on actions implemented to address identified problems.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managersensure designated employees receive evacuation device training and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the policy for safe use of automated dispensing machines to include training and minimum competency requirements for users and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that radiologists document the radiation dose in the Computerized Patient Record System and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently use appropriate note titles to document advance directive screening and that facility managers monitor compliance.
No. 12
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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management scope of practice have a statement related to emergency airway management included in the scope of practice.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility consistently perform continuing stay reviews on at least 75 percent of patients in acute beds.