Healthcare Inspection – Mental Health-Related Concerns, W. G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina

OIG conducted a review to assess allegations of inadequate mental health (MH) care of a specific patient and poor utilization of MH beds at the W. G. (Bill) Hefner VA Medical Center (facility) Salisbury, NC. We did not substantiate that a patient was discharged prematurely, denied readmission due to a lack of acute MH beds, and subsequently committed suicide. After being hospitalized for a week on the acute MH unit, the patient was evaluated by Psychiatrist A who completed a suicide risk assessment, noted the patient was at low risk for suicidal behaviors, did not meet criteria for involuntary commitment, and could not be held against his will. The patient requested to be discharged and was discharged. A few weeks later, the patient presented to the emergency department (ED) with suicidal ideation. As the acute MH unit was full, the patient was admitted to a medicine unit on one-to-one observation (second hospital stay). An acute MH unit bed became available, but the patient declined transfer and requested discharge. Psychiatrist C determined the patient was at low risk for suicidal behaviors and not appropriate for admission. The patient was discharged. We did not substantiate the patient committed suicide. The autopsy report attributed the cause of death to combined drug toxicity and classified the manner of death as accidental. We found a lack of communication and coordination between ED staff, medical unit staff, Psychiatrist C, and the suicide prevention team during the patient’s second hospital stay. The Suicide Prevention Team was not routinely notified by staff when a patient designated high risk was being treated in the ED or inpatient unit and some team members were not fully aware of their role and responsibilities. While we confirmed that the acute MH was frequently near capacity and the chronic MH unit did not accept “overflow” patients, we did not substantiate the implied inappropriateness of the condition. Facility leaders were aware of the problem and actively recruiting for inpatient psychiatrists which would permit full conversion of some chronic MH beds to acute MH beds. We made one recommendation.