Breadcrumb

Healthcare Inspection - Mismanagement of Inpatient Mental Health Care, Atlanta VA Medical Center, Decatur, Georgia

Report Information

Issue Date
Report Number
12-03869-179
VISN
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG evaluated allegations regarding the Mental Health Service Inpatient Unit at the Atlanta VA Medical Center (facility), Decatur, GA. Specifically, the complainant alleged that an inpatient’s death was due to mental health service leadership’s negligence and mismanagement of unit policies, patient monitoring, staffing, and lack of caring about patients. We did not substantiate the allegations of inadequate staffing, inappropriate staff assignments, or that leadership did not care about patients. However, we substantiated that the facility did not have adequate policies or practices for patient monitoring, contraband, visitation, and urine drug screening. We found inadequate program oversight including a lack of timely follow up actions by leadership in response to patient incidents. We recommended that the Under Secretary for Health ensure that VHA develops national policies to address contraband, visitation, urine drug screening, and escort services for inpatient mental health units. We also recommended that the VISN and Facility Directors ensure that the inpatient mental health unit develops these policies; strengthen program oversight and follow-up; improve communication with staff; and ensure functional and well-maintained life support equipment.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health develops national policies that address contraband, visitation, urine drug screens, and escort services for inpatient mental health units.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit develops and implements policies that adequately address contraband, visitation, urine drug screening, and escort service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit employs safeguards for documentation that accurately reflect staff observation of patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health unit strengthens program oversight including follow-up actions taken by leadership in response to patient incidents.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility strengthen and improve the RCA process to ensure that all information and documentation related to the event are reviewed and that follow up actions are completed and timely.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility improves communication with staff regarding debriefings and planned actions to address identified deficiencies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility inpatient mental health units are equipped with functional and well-maintained life support equipment.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the VISN and Facility Directors ensure that the facility evaluates the care of the subject patient with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patient.