Healthcare Inspection - Alleged Patient Safety Concerns, Miami VA Healthcare System, Miami, Florida

OHI conducted an inspection at the request of Chairman Jeff Miller, Committee on Veterans’ Affairs, US House of Representatives, and Chairman Mike Coffman, Subcommittee on Oversight and Investigations, Committee on Veterans’ Affairs, US House of Representatives. The OIG team assessed allegations that the Miami VA Healthcare System (system), Miami, FL, lacked adequate patient safety policies and procedures to safeguard patients when they “come and go” from the Community Living Center (CLC) and whether additional safety measures could have prevented a patient’s suicide. We did not substantiate the allegation that the CLC lacked adequate safety policies and procedures regarding patients’ “comings and goings” in the CLC. We found that the system had policies and procedures addressing various aspects of patient safety in the CLC. However, we found that system staff did not consistently enforce certain policies and procedures when the patient did not comply with them. We could not substantiate the allegation that the system should have instituted additional safety precautions given the patient’s past medical and mental health history. However, we identified additional potential suicide risk factors known to at least one staff member that were not documented or discussed in the CLC Interdisciplinary Team meetings. We also found that staff did not initiate an Integrated Ethics consult, which should have been done to assist them and the patient in making informed decisions and applying appropriate healthcare ethics standards regarding medical care, treatment, and patient autonomy. By failing to consistently enforce certain policies and procedures and initiate an Integrated Ethics consult, system staff missed opportunities to intervene with this patient. Although a system internal review addressed some specific issues pertaining to patient care, it did not reflect and document an in-depth exploration of possible event causes. We made four recommendations.