Clinical Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana

Report Information

Issue Date
Report Number
16-00574-151
VISN
State
Arkansas
Louisiana
Texas
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
20
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided at the Overton Brooks VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care, Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 411 employees. OIG identified certain system weaknesses in utilization management; general safety; environmental cleanliness; anticoagulation processes; transfer documentation and data collection; history and physical examinations for moderate sedation procedures; community nursing home annual reviews and clinical visits; processes, procedures, and training for management of disruptive and violent behavior; and treatment of alcohol use disorder. As a result of the findings, OIG could not gain reasonable assurance that: (1) physician advisors provide input for utilization management decisions, (2) patient care areas are safe and clean, (3) anticoagulation patients can contact employees after hours, (4) clinicians use laboratory tests to initiate and monitor anticoagulation therapy and provide transition follow-up for discharged patients newly prescribed anticoagulants, (5) the facility safely transfers patients to other facilities and uses transfer data to improve care, (6) providers assess patients prior to moderate sedation, (7) employees monitor and follow up on community nursing home patients, (8) the facility works to prevent disruptive behaviors, (9) clinicians notify patients of rights related to flags in their medical records, and (10) clinicians offer further treatment to patients diagnosed with alcohol dependence. OIG made recommendations for improvement in the following seven areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Moderate Sedation; (6) Community Nursing Home Oversight; and (7) Management of Disruptive/Violent Behavior.

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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Environment of Care Committee meeting minutes consistently document corrective actions taken to address rounds deficiencies and consistently track actions taken in response to identified deficiencies to closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility repair rusted equipment in patient care areas or remove it from service.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure sinks in patient nourishment kitchens are clean and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the hemodialysis unit manager ensure sinks and floors are clean and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the hemodialysis unit manager ensure clean and dirty items are stored separately and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility collect and report data on patient transfers out of the facility as required by local policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes are written by a staff/attending physician or are written by an accceptable designee and contain a staff/attending physician countersignature.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include the evaluation of previous adverse events with anesthesia in the history and physical and pre-sedation assessment and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement an Employee Threat Assessment Team and that the VA Police Officer and Risk Manager consistently attend Disruptive Behavior Committee meetings.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to appeal Patient Record Flag placement.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure appropriate individuals conduct debriefings after incidents of disruptive or violent behavior and monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive Level 1 training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that community based outpatient clinic/primary care clinic employees consistently document the offer of further treatment to patients diagnosed with alcohol dependence.