Combined Assessment Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri

Report Information

Issue Date
Report Number
15-00600-33
VISN
State
Missouri
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 90 employees. This review focused on seven operational activities and a follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the following two activities (1) medication management and (2) advance directives. The facility’s reported accomplishment was increased veteran outreach. OIG made recommendations for improvement in the following six activities, which includes the follow-up review area: (1) quality management, (2) environment of care, (3) coordination of care, (4) computed tomography radiation monitoring, (5) emergency airway management, and (6) follow-up on long-term home oxygen therapy.

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 independent practitioners who perform emergency airway management have the appropriate skills and training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the privileges to do so.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure emergency airway management privileges for licensed independent practitioners are reviewed, signed, and dated prior to granting the privileges.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Cardiopulmonary Resuscitation Committee review all episodes of care where resuscitation was attempted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure the recently established Safe Patient Handling Committee continues to meet and provide oversight of the safe patient handling program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all sharps containers are sealed tightly at the point of collection and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure evacuation devices are immediately accessible in patient care areas and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for all construction projects, the facility initiate Interim Life Safety Measures as required and post any needed alternative exit signage and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 10
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the computed tomography policy to include a quality control program.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the emergency airway management policy to include a plan to manage a difficult airway.
No. 13
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 elements 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 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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and in instances of occurrence, initiate root cause analyses.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure all home oxygen patients are assessed for continuation of home oxygen within 90 days of the initial order and that facility managers monitor compliance.