The Department of Veterans Affairs Office of Inspector General (VA OIG) recently conducted an investigation into events at the West Palm Beach VA Medical Center in Florida where a patient housed in the Center’s locked mental health unit committed suicide in early 2019. The unit was a high-intensity care unit that serves 25 beds as a “stabilization program for Veterans in acute mental distress.” The OIG investigation ultimately found that the patient received “reasonable clinical assessment, treatment, and discharge planning services.”

Although risk assessment rounds were conducted on the unit every six months as required by VHA Directive 1167, the OIG found that (1) the facility did not meet expectations of the Interdisciplinary Safety Inspection Team (ISIT), (2) Mental Health Environment of Care Checklist (MHEOCC) training was inadequate, (3) members of the ISIT inspection team failed to consistently report non-compliant or unsafe conditions in the facility, and, (4) ultimately, oversight was not consistently implemented at the facility, Veterans Integrated Service Network (VISN), and Veterans Health Administration levels. The facility lacked a MHEOCC policy altogether and neither an ISIT team nor a EOC (Environment of Care) subcommittee ever existed at the facility. Only 44% of the employees required to have MHEOCC training completed it in compliance with VHA Directive 1167. Cameras used to monitor the unit were non-operational for years due to a lack of network connection.

The OIG judged staffing to be sufficient on the day of the death, but the nurse responsible for completing 15-minute safety rounds violated protocol by performing other duties during that time, perhaps delaying her from completing her next round. In March 2019, the OIG team noted that the facility lacked clear expectations or policies about the duties of the 15-minute safety rounds. Overall, the OIG found that leadership at the facility displayed a lack of awareness and care of patient safety requirements which constituted a “deflection of responsibility and failure to perform their duties.”

In its 2019 customer experience principles, the Department of Veterans Affairs aims to “provide the best customer experience in its delivery of care, benefits, and memorial services to veterans, servicemembers, their families, caregivers, and survivors. The delivery of exceptional customer experience is the responsibility of all VA employees and will be guided by VA’s Core Values and Characteristics.” This suicide seems to show that the VA failed in meeting its core values.

In 2016, the United States population overall had over 44,000 suicide deaths, a rate of about 14.5 suicides per 100,000 people. The rate for non-veteran adults was 16.4 suicides per 100,000 in 2016. In the same year, the suicide rate among Veterans was 30.1 per 100,000 with over 6,000 total deaths. Most occur outside in the community, but suicides in health facilities are not unheard of. Inpatient suicide is reportedly considered a “never event” (defined in the investigation report as “an adverse event that is clearly identifiable, results in death or significant disability, and is usually preventable”) which prompted the investigation. The VA facility should have had appropriate mechanisms in place to prevent this from happening.

The OIG made 11 recommendations in its investigation report, two to VA executives, identifying areas where higher-ranking officials need to improve their oversight. The Office called on the VISN Director to ensure that VISN level staff comply with guidelines to review semi-annual reports and follow-up to see that “abatement of deficiencies” is completed. The second recommendation, made to the Under Secretary of Health, called for action to ensure the MHEOCC reviews and prioritizes hazards and makes sure that those problems are rectified as indicated in the Patient Safety Assessment Tool.

The Under Secretary of Health’s action plan, a component of his response to the OIG’s report, assured that “any environmental suicide hazard that is identified by the facility must be abated or appealed to the MHEOCC review board” within six months of the hazard being identified. The VISN Director asserted that VISN 8 staff officers would collaborate as a team to continuously determine if appropriate risk mitigation strategies were in place going forward. It remains to be seen whether those commitments will be fulfilled.