Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina

Report Information

Issue Date
Report Number
16-00576-310
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
26
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the W.G. (Bill) Hefner 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 (CNH) Oversight; Management of Disruptive/Violent Behavior; and Mental Health Residential Rehabilitation Treatment Program (MH RRTP). OIG provided crime awareness briefings to 71 employees. OIG identified certain system weaknesses in utilization management, general safety, environmental cleanliness, anticoagulation patient education, transfer documentation, glucometer quality control testing, moderate sedation processes and documentation, CNH oversight and clinical visits, disruptive/violent behavior documentation and employee training, and MH RRTP inspections and environmental safety. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Has effective documentation, communication, and quality improvement processes for decisions involving utilization management; (2) Maintains a clean environment of care in the Emergency Department and has a policy and procedure for the reprocessing of reusable medical equipment; (3) Maintains a safe environment of care with consistent fire drills, labels food items in the nourishment refrigerators, and secures chemicals in the hemodialysis unit; (4) Provides effective anticoagulation therapy management patient education; (5) Has a safe inter-facility transfer process; (6) Performs quality control testing on glucometers; (7) Provides safe moderate sedation care; (8) Provides effective CNH oversight; (9) Has an effective process for the management of disruptive/violent behavior; (10) Maintains a safe MH RRTP environment. OIG made recommendations for improvement in the following nine review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Diagnostic Care; (6) Moderate Sedation; (7) CNH Oversight; (8) Management of Disruptive/Violent Behavior; and (9) MH RRTP.

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 facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure air conditioner and steam/heat ventilation grills in the Emergency Department are clean and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure refrigerators in patient nourishment kitchens do not contain unlabeled food items and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility implement a policy for cleaning, disinfecting, and sterilizing reusable medical equipment.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure standard operating procedures for the colonoscope, esophagogastroduodenoscope, and duodenoscope are consistent with the manufacturers' instructions for use.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers consistently complete VA form 10-2649A or use a properly templated inter-facility transfer note template for patients transferred out of the facility and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in VA Form 10-2649A, Inter-Facility Transfer Form, and that facility managers monitor compliance.
No. 11
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 include a staff/attending physician countersignature and monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that sending nurses document transfer assessments/notes for patients transferred out of the facility and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that for emergent transfers, provider transfer notes include a statement of patient stability for transfer and that facility managers monitor compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees perform quality control on glucometers in accordance with the facility's policy/standard operating procedure and the manufacturer's recommendations and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers include history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinical employees discharge outpatients from the recovery area with orders given by a qualified provider or according to criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility integrate the community nursing home program into its quality improvement program.
No. 20
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. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure Disruptive Behavior Committee discussion of patients' disruptive or violent behavior and entry of a progress note into the patients' electronic health records.
No. 22
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 request to amend/appeal Patient Record Flag placement.
No. 23
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, ensure training is documented in employee training records, and monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document every 2-hour rounds of all public spaces, daily bed checks, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Substance Abuse Residential Rehabilitation Treatment Program unit's non-main entry door is alarmed at all times and that program managers monitor compliance.