OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection - Mismanagement of Inpatient Mental Health Care, Atlanta VA Medical Center, Decatur, Georgia
Report Number: 12-03869-179 Download
Issue Date: 4/17/2013
City/State: Decatur, GA
Atlanta, GA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

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.