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Report File
Title Full
Care Failures for a Patient with Alcohol Withdrawal at the Hampton VA Medical Center in Virginia
Date Issued
Submitting OIG
Department of Veterans Affairs OIG
Agencies Reviewed/Investigated
Department of Veterans Affairs
Report Number
24-02232-87
Report Type
Inspection / Evaluation
Location

Hampton, VA
United States

Number of Recommendations
7
Questioned Costs
$0
Funds for Better Use
$0
Report updated under NDAA 5274
No
External Link
https://www.vaoig.gov/reports/hotline-healthcare-inspection/care-failures-patie…

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
01 No $0 $0

The Hampton VA Medical Center Director directs nursing leaders to review records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale Protocol orders to confirm that medical intensive care unit nurses document Clinical Institute Withdrawal Assessment of Alcohol Scale scores consistent with patients documented behavior and symptoms and takes actions to address any deficiencies that are identified.

02 No $0 $0

The Hampton VA Medical Center Director confirms that nursing leaders complete review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to determine the extent with which administration of medication is in adherence with the protocol and take actions to address any deficiencies that are identified.

03 No $0 $0

The Hampton VA Medical Center Director ensures that a review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders is completed by nursing leaders to (a) assess the degree of compliance with completing Clinical Institute Withdrawal Assessment of Alcohol Scale assessments based on the last assessment score, as outlined in the protocol, and (b) review the actual time Clinical Institute Withdrawal Assessment of Alcohol Scale is completed in comparison to the time it is documented in the electronic health records to identify significant delays, if any, and based on analysis of findings, takes action to address deficiencies that are identified.

04 No $0 $0

The Hampton VA Medical Center Director works with the facility Chief of Staff to ensure medical intensive care unit providers have reviewed a clinical practice guideline specific to management of alcohol withdrawal from an accredited source, such as The American Society of Addiction Medicine.

05 No $0 $0

The Hampton VA Medical Center Director confirms completion of a review to assess the current process for communicating unit-based medication shortages and how staff can confirm the availability of shortage medications when use of the medication is key to the patients treatment, and updates the process as warranted.

06 No $0 $0

The Hampton VA Medical Center Director ensures that the facilitys Alcohol Withdrawal Management standard operating procedure aligns with requirements for a standard operating procedure outlined in Veterans Health Administration Notice 2024-09.

07 No $0 $0

The Hampton VA Medical Center Director confirms that training requirements specified in Veterans Health Administration Notice 2024-09 are completed, training attendance is tracked, and a process is in place to monitor accurate and consistent use of the alcohol withdrawal scale identified in the facility standard operating procedure

Department of Veterans Affairs OIG

United States