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VA calls for 45 changes in St. Louis veterans health care

John Cochran hospital
File photo
John Cochran VA Hospital in St. louis has resumed surgeries. (SLPR news)

Missouri’s U.S. senators, Republican Roy Blunt and Democrat Claire McCaskill, say they are concerned with the latest findings in a review of operations, at the VA’s St. Louis Health Care System.

The review makes 45 recommendations for improvements, ranging from sanitation to management inconsistencies. In a letter to the acting director of the facility, Patricia Ten Haaf, the senators ask to be kept informed of her plans to address the findings and “specific corrective actions. ... Our veterans have earned and deserve the very best in treatment and services,” both write.

The senators note in their letter that Ten Haaf, is the seventh acting medical director of the facility within the past two years. “The high turn-over rate in this position and others could very well be a compounding factor in the issues raised in the CAP (Combined Assessment Program) review.” 

The review covered facility operations for Fiscal 2014-15 through March 6 of this year and recommends improvements in areas including:

  • Quality Management
  • Environment of Care
  • Medication Management
  • Surgical Complexity
  • EAM (Emergency Airway Management) Which is a set of medical procedures performed to prevent airway obstruction in patients
  • Mental Health Residential Rehabilitation Treatment Program

General Environment of Care, for example, includes issues with expired medications, medications missing “beyond use date” labels and “pharmacy prepared medications without expiration dates.” It said, “Four patient care areas contained opened multi-dose vials with beyond-use dates greater than the 28 days required by local policy.”
Other "environment of care" issues were dirty floors and dust on surfaces in patient care areas, public restrooms with “dirty blinds, grout, floors, walls, and vents.” In three out of 11 patient care areas, clean and dirty items were stored together. Broken furniture was found in three patient care areas and, in two cases, oxygen tanks "were not stored in a manner that distinguished between empty and full tanks.” The report said this was a repeat finding from a 2011 review.

Under Medication Management, the report said one of the “emergency crash cart” logs contained incorrect lock numbers; reference materials were missing for “look-alike and sound-alike medications,” and “the facilities high-alert medication list was not available for staff reference.” 

The Emergency Airways Management section including several cases where staff members “did not have reassessments for continued EAM competency completed" and during none of the 30 days that were sampled was "appropriate EAM coverage (available) during all hours the facility provided patient care.” 

The report also found that the facility’s Mental Health Residential Rehabilitation Treatment Program “did not have a consistently secure main point of entry.” The review recommends that facility managers ensure that only authorized patients, staff and visitors access the area.

The Office of Inspector General for the Department of Veterans Affairs released its report on the review, known as a Combined Assessment Program, on Monday.

Both the director of the Veterans Integrated Service Network, William P. Patterson, and the deputy medical center director, Keith Repko, concurred with all of the review’s findings and recommendations for improvement. Dr. John D. Daigh Jr., assistant inspector general for Healthcare Inspections said in the review’s executive summary that Patterson and Repko provided acceptable improvement plans. He also said the Inspector General’s Office will follow up on the planned actions until they are completed.