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Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas

Inspection / Evaluation · Department of Veterans Affairs OIG · 2021-08-18 · about Department of Veterans Affairs

Report

Title
Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas
Submitting OIG
Department of Veterans Affairs OIG
Component agency
Department of Veterans Affairs
Type
Inspection / Evaluation
Publication date
2021-08-18

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E.

Recommendations (9)

#StatusText
1ClosedThe Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
2ClosedThe Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA…
3ClosedThe Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
4ClosedThe Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while…
5ClosedThe Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
6ClosedThe Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
7ClosedThe Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
8ClosedThe Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
9ClosedThe Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.

Source

Authoritative
oversight.gov report page
Machine
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