Healthcare Inspection – Emergency Department Evaluation of a Homeless Veteran VA North Texas Health Care System, Dallas, Texas

The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection to determine the validity of an allegation related to a patient being denied inpatient mental health treatment at the VA North Texas Health Care System (facility) in Dallas, TX. Specifically, the complainant alleged that a patient presented to the Emergency Department (ED) with suicidal ideation and had to wait in the triage holding area for over 4.5 hours prior to being seen by a psychiatrist. The psychiatrist told the patient that admission was not indicated. The patient had a panic attack, and the police were called to escort the patient out of the facility as the patient was upsetting the staff. We did not substantiate that a suicidal patient was denied admission for inpatient treatment. We interviewed staff, reviewed the patient’s electronic health record, and reviewed facility policies. Although the patient’s electronic health record documented the patient was hopeless and depressed, it also documented that the patient denied suicidal ideation. We determined that there was no facility policy or standard operating procedure written to describe the process for patient evaluations in the ED; therefore, there was no training on such a policy or procedure for anyone working in the ED. This may have contributed to the long ED visit for the patient and influenced the patient’s decision to leave against medical advice. We also reviewed the patient’s ED Integration Software (EDIS) tracking sheet that is used to monitor a patient’s real-time movement through the ED. The tracking sheet did not match the patient’s electronic health record. ED administrative and clinical staff do not consistently update EDIS as required. In addition, social workers on call for the ED after hours did not assist homeless patients to find a shelter or direct them to the Healthcare for Homeless Veterans program as required. We recommended that the Facility Director ensure that the facility develops a written policy for ED patient evaluation and provide orientation to all ED staff and on-call personnel; EDIS is used as required; and social work services are provided in the ED as required. The Veterans Integrated Service Network and Facility Directors agreed with our findings and recommendations and provided acceptable improvement plans.