Comprehensive Healthcare Inspection Program Review of the VA Long Beach Healthcare System, Long Beach, California

Report Information

Issue Date
Report Number
17-01739-31
VISN
State
California
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
14
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Long Beach Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 151 employees. The facility has generally stable executive leadership to support patient safety and quality care. However, the presence of multiple organizational risk factors, such as adverse event disclosures, reported in-hospital complications, and adverse events following surgeries and procedures, may contribute to future issues of lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care metrics. OIG noted findings in five areas of clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data (2) Medication Management: Anticoagulation Therapy • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Documentation of informed consent and patient stability for transfer • Resident supervision • Communication with accepting facility (4) Environment of Care • General safety and cleanliness • Infection prevention risk assessment • Dirty and used equipment storage • Panic alarm and security surveillance television system testing  (5) Long-Term Care: Community Nursing Home Oversight • Oversight committee membership • Program integration • Cyclical clinical visits

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)
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent and medical and/or behavioral stability in transfer documentation and monitors providers’ compliance
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for inter-facility transfers, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures that facility managers maintain a safe and clean environment throughout the facility and the Santa Ana Outpatient Primary Care Clinic and monitors the managers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that facility managers conduct annual infection prevention risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures that dirty and used equipment is stored separately from sterile supplies.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures that staff regularly test panic alarms at the Santa Ana Outpatient Primary Care Clinic.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures that staff regularly test camera surveillance equipment on the locked mental health unit and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Assistant Director ensures that the locked mental health unit clean/sterile supply rooms are clean and that used equipment is stored separately from sterile supplies.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff and Associate Director for Patient Care Services ensure the Community Nursing Home Oversight Committee includes representation by all required disciplines.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures that the social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors the social workers’ and registered nurses’ compliance.