Clinical Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan

Report Information

Issue Date
Report Number
16-00549-302
VISN
State
Michigan
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 an evaluation of the Aleda E. Lutz VA Medical Center. This included reviews 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 252 employees. OIG identified certain system weaknesses in credentialing and privileging; utilization management; general safety; anticoagulation processes; transfer documentation; point-of-care testing processes; moderate sedation processes and training; Community Nursing Home Oversight Committee representation, annual reviews, and clinical visits; and management of disruptive or violent behavior processes and training. As a result of the findings, OIG could not gain reasonable assurance that: (1) Ongoing Professional Practice Evaluation data and utilization management data are reviewed; (2) Medications in carts are secured from unauthorized access; (3) Clinicians obtain all required laboratory results after initiating anticoagulants, document all required elements for patient transfers, and take and document all actions required in response to test results; (4) The facility documents required elements for moderate sedation and ensures training is in place; (5) The facility provides community nursing home program oversight and ensures annual and cyclical clinical visits of nursing homes; (6) The facility minimizes disruptive/violent behavior and trains employees to manage this behavior; (7)Clinicians inform patients about Patient Record Flags and the right to request to amend/appeal, and the Chief of Staff/designee approves Orders of Behavioral Restriction. OIG made recommendations for improvement in all eight review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management: Anticoagulation Therapy; (4) Coordination of Care: Inter-Facility Transfers; (5) Diagnostic Care: Point-of-Care Testing; (6) Moderate Sedation; (7) Community Nursing Home Oversight; and (8) 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 facility clinical managers review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility repair malfunctioning medication carts or remove them from service.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts prior to moderate sedation procedures and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical managers ensure that licensed independent practitioners who perform moderate sedation procedures complete required training for the provision of moderate sedation care and that training is documented and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all required disciplines attend Community Nursing Home Oversight Committee meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
No. 11
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 for community nursing home oversight and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Disruptive Behavior Committee [DBC] maintains meeting minutes and a record of attendance for key committee members and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure employees consistently use the disruptive behavior reporting and tracking system and monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure clinicians inform patients about the right to request to amend/appeal Patient Record Flag placement.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility clinical managers ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior 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.