Clinical Assessment Program Review of the Wilmington VA Medical Center, Wilmington, Delaware

Report Information

Issue Date
Report Number
16-00548-361
VISN
State
Delaware
New Jersey
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) evaluated the quality of care at the Wilmington VA Medical Center. This included reviews of key processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care (EOC); Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home (CNH) Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 84 employees. OIG identified certain system weaknesses in EOC Committee meeting minutes; general safety; Sterile Processing Service (SPS) employee competencies; hemodialysis unit infection prevention; anticoagulation processes and employee competencies; transfer data and documentation; point-of-care testing actions; CNH oversight, clinical visits, and policies; and management of disruptive/violent behavior policy, committee representation, and employee training. As a result of the findings, OIG could not gain reasonable assurance that: (1) EOC minutes track actions taken for deficiencies until closed. (2) Community based outpatient clinic (CBOC) fire extinguishers are inspected monthly, and CBOC information technology network room logs contain access documentation. (3) SPS employees complete annual competencies. (4) Hemodialysis unit employees wear gloves when handling patient equipment. (5) Clinicians obtain required laboratory testing prior to initiating anticoagulants and have documented competency to manage anticoagulation therapy patients. (6) The facility collects and reports data on transfers out and includes required elements in transfer documentation. (7) The facility takes and documents all required actions in response to glucose point-of-care testing results. (8) The facility oversees the CNH program and performs cyclical reviews of care provided. (9) The facility’s disruptive behavior policy reflects current practice, members attend committee meetings, and employees are trained to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following six reviews: (1) EOC, (2) Medication Management, (3) Coordination of Care, (4) Diagnostic Care, (5) CNH Oversight, and (6) 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 Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure all fire extinguishers are inspected monthly and marked with the correct date and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees document when they access information technology network rooms by using the visitor logs and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive annual competencies for the types of reusable medical equipment they reprocess.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that hemodialysis unit employees wear gloves when handling patient equipment and that the hemodialysis unit manager monitors compliance.
No. 6
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 warfarin treatment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for employees actively involved in the anticoagulant program, clinical managers include in the competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
No. 9
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 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, clinicians consistently include documentation of patient or surrogate informed consent and of medical and behavioral stability in transfer documentation and that facility managers monitor compliance.
No. 11
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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
No. 14
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. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility update its policy on the community nursing home program to include all elements required by Veterans Health Administration policy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that a VA physician order or approve all therapies that are at VA expense.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure the community nursing home program office scans existing paper health records into electronic health records and develops a process to scan new records as they are received.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the facility update its policy on preventing and managing disruptive and violent behavior.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VA Police Officer and the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 20
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 training is documented in employee training records.