The surprise visit happened the week of Jan. 28, 2019. The report highlighted deficiencies in six of the eight clinical areas reviewed and made 13 recommendations for Roudebush VAMC to take action on.
One of the recommendations is for them to replace or repair damaged wheelchairs. The OIG found wheelchairs with damaged or missing armrests in five patient care units and in lobbies or corridors in four locations. Some of the wheelchairs had vinyl coverings that were cracked or torn, which means they could not be effectively cleaned, risking the chance of spreading infection.
Another recommendation was to review the monthly and quarterly controlled substance inspection reports. The Veterans Health Administration requires those reports to be reviewed at least quarterly. According to the OIG, meeting minutes reviewed from July to December 2018 found no evidence the controlled substance inspection reports were reviewed by the Quality Management Committee. Roudebush’s controlled substance coordinator cited a lack of attention to detail for not reviewing the minutes.
A positive note of the report is patients report having a good experience at Roudebush VAMC, rating higher than the VHA average.
You can review the full report here.
In that report you will find the corrective action Roudebush VAMC will be making in response to the OIG’s findings. We’ve also reached out to them for a statement on this report.
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