Healthcare Inspection – Emergency Department, Mental Health Service, and Suicide Prevention Training Concerns, Mann-Grandstaff VA Medical Center, Spokane, Washington

OIG conducted an inspection at the request of Senator Patty Murray at the Mann-Grandstaff VA Medical Center (facility), Spokane, WA, in response to allegations of failures in Emergency Department (ED) care, mental health services, and suicide prevention training. We did not substantiate a failure to actively recruit and retain qualified ED providers. We did not substantiate the facility’s change from an ED to an Urgent Care Clinic (UCC) with a reduction in operating hours resulted in a deficiency in care. We determined the facility was thoughtful in planning an approach to align the delivery of care with resources thereby reducing the potential for adverse events after the loss of ED providers. Facility leaders took steps to inform the public before changing to a UCC and tracked after-hour attempts to access care once the change occurred. We did not substantiate that quality of care issues contributed to the death by suicide of a patient. We determined that from the time of his initial contact until his last contact with the facility’s mental health staff, the patient was assessed by an interdisciplinary team for risk of suicide and determined to be not at risk for self-harm. We substantiated that facility leaders failed to comply with VHA requirements for suicide prevention training. We found that not all health care providers who required training had completed the Suicide Risk Assessment for Clinicians course within the required first 90 days of hire and the facility lacked a process to assign and track the required training that has since been resolved. Only three staff were delinquent in completion of the training as of May 17, 2016. At the time of publication we closed our recommendation that the Interim Facility Director strengthen processes to ensure suicide prevention training is completed per VHA requirements and monitor compliance.