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Healthcare Inspection – Patient Care Deficiencies and Mental Health Therapy Availability, Overton Brooks VA Medical Center, Shreveport, Louisiana

Report Information

Issue Date
Report Number
14-05075-447
VISN
State
Louisiana
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted inspections in response to two complaints received from Senator Richard Burr, then-Ranking Member of the Senate Veterans’ Affairs Committee, concerning patient care deficiencies and the availability of mental health (MH) therapy at the Overton Brooks VA Medical Center (facility), Shreveport, LA. We did not substantiate that patients did not have enough linen or that it was of insufficient or poor quality. We substantiated the allegation that toiletries were provided by volunteer organizations and unit staff. We did not substantiate that a general lack of concern exists among nursing staff for patients or that nursing assistants do not follow the nursing chain of command. We substantiated that a patient died on a telemetry unit while not being actively monitored as ordered at the time of his death. OIG Office of Investigations reviewed the events surrounding the patient’s death, reviewed the findings from a facility-conducted Administrative Investigation Board, and ultimately closed the case. We did not substantiate that MH group therapy programs are being dismantled or decimated. We did not substantiate that MH staff have had to maintain large support groups in order to keep veterans stable while waiting for individual treatment. We did not substantiate that the facility is severely understaffed with MH therapists. We substantiated an allegation received onsite that some patients who received MH care were lost to follow-up. In early 2014, during the planning and implementation phases of establishing two Behavioral Health Interdisciplinary Program teams, the facility identified roughly 400 patients receiving MH care who were lost to follow-up and subsequently took appropriate actions. We recommended that the Facility Director ensure patients are notified and re-assigned timely when their MH providers leave the facility.

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 Facility Director ensure patients are notified and re-assigned timely when their mental health providers leave the facility.