Healthcare Inspection – Evaluation of a Patient’s Care and Disclosure of Protected Information, Atlanta VA Medical Center, Decatur, Georgia

At the request of the Chairman and Ranking Member, Senate Committee on Veterans’ Affairs and the Chairman and Ranking Member, House Committee on Veterans’ Affairs, OIG conducted a review of a patient’s care at the Atlanta VA Medical Center (facility), Decatur, GA prior to the patient’s death and evaluated an improper disclosure of protected health information outside VA. We determined that facility staff provided, or attempted to provide, appropriate mental health (MH) treatment and psychosocial support services. Although the veteran verbalized suicidal ideation, she was reluctant to engage in psychotherapy. The veteran missed two MH appointments, but when contacted, exercised her right and declined further MH services. We identified appointment scheduling and follow-up deficiencies, a 23-day delay in placing a high-risk for suicide flag, and inconsistent compliance with some high-risk protocol requirements. However, we do not believe that these deficiencies had a direct impact on the outcome, as the veteran died more than 2 months after she was referred for placement on the high-risk protocol, more than a month after the missed MH appointments, and 1 week after a face-to-face contact with a clinician. We confirmed that information in the veteran’s electronic health record was improperly disclosed. The record was designated as “non-sensitive” at the time of the disclosure, and Veterans Health Administration currently lacks the ability to audit access to non-sensitive records. We recommended that the Interim Under Secretary for Health evaluate options to identify individuals who access non-sensitive patient EHRs. We also recommended that the facility Director ensure that staff comply with guidelines for appointment scheduling, notification, and follow-up; make patient contacts in accordance with treatment plans; and adhere to suicide prevention program requirements. The Interim Under Secretary for Health, and the Veterans Integrated Service Network and facility Directors, concurred with our recommendations and provided acceptable action plans.