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Combined Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan

Report Information

Issue Date
Report Number
13-03623-89
VISN
State
Michigan
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the review was 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 218 employees. This review focused on seven operational activities. The facility complied with selected standards in the following three activities: (1) environment of care, (2) medication management, and (3) coordination of care. The facility’s reported accomplishments were the opening of a physical therapy satellite clinic in the community living center and the Veterans Transportation Service, which provides timely and efficient transportation to outpatients traveling to and from scheduled medical appointments at the facility. OIG made recommendations for improvement in the following four activities: (1) quality management, (2) nurse staffing, (3) pressure ulcer prevention and management, and (4) community living center resident independence and dignity.

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 processes be strengthened to ensure that the ICU Committee reviews each code episode.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the MRC analyze all reports of EHR quality review results
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that a member from Surgery Service attends Ancillary Testing Committee meetings, that a clinical representative from Anesthesia Service is added as an Ancillary Testing Committee member, and that the blood/transfusions usage review process includes the results of peer reviews when transfusions did not meet criteria.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff provide timely restorative nursing services to residents who are candidates for those services and that compliance be monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals, modify interventions as needed, and document the modifications and that compliance be monitored.