Combined Assessment Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada

Report Information

Issue Date
Report Number
15-00625-37
VISN
State
Nevada
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
15
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 174 employees. This review focused on eight operational activities and one follow-up review area from the previous Combined Assessment Program review. The facility complied with selected standards in the computed tomography radiation monitoring activity. The facility’s reported accomplishments were employee engagement efforts to improve communication, several quality and continuous improvement activities, and an emergency preparedness exercise. OIG made recommendations for improvement in the following eight activities, which includes the follow-up review area: (1) quality management, (2) environment of care, (3) medication management, (4) coordination of care, (5) advance directives, (6) surgical complexity, (7) emergency airway management, and (8) follow-up on medication management issue.

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 receive the appropriate training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies and specifics, including the deficiency, location, action, and resolution and any trends.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers monitor the use of clean biohazard bags to ensure they are used appropriately.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure designated employees receive emergency evacuation device training and competency assessment and revise the local policy to define expectations for competency assessment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility use special medication labeling for look-alike and sound-alike medications and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that oral syringes are available for liquid medications in the Emergency Department and on the intensive care-step down unit and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
No. 8
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility revise the local policy to address advance directive notification, screening, and discussions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
No. 11
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Radiology Service revise its policies to require a 30-minute on-call reporting time for computed tomography scans and a 30-minute on-call response time for radiology interpretation.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure clinicians complete all required emergency airway management competency reassessment elements prior to providing emergency airway management coverage and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility have appropriate emergency airway management coverage 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 ensure that identified deficiencies from the annual pharmacy physical security survey are corrected and monitor compliance.