Deficiencies in Discharge Planning for a Mental Health Inpatient Who Transitioned to the Judicial System from a Veterans Integrated Service Network 4 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the discharge of a patient from an inpatient mental health unit at a Veterans Integrated Service Network 4 Medical Facility. The patient was arrested by VA Police, discharged to a federal detention center (FDC), and died eight days later. The OIG identified concerns related to discharge planning processes, voluntary and involuntary admission, use of guidance regarding the patient’s legal and psychiatric status, and patient record flag management. The OIG did not substantiate that the patient died by suicide in the FDC. The Associate Medical Examiner identified the cause of death as hypertensive and atherosclerotic cardiovascular disease and the manner of death as natural. The OIG substantiated that facility staff failed to engage in proper treatment and discharge planning processes. Specifically, staff failed to: • Include the patient and family in treatment and discharge planning, • Address the patient’s decision-making capacity, • Identify and consistently document the patient’s surrogate, • Provide clinical hand-off communication to the receiving mental health providers, despite the patient’s medical and psychiatric acuity and complex medication regimen, • Assign a mental health treatment coordinator, • Obtain a release of information for the VA Police to obtain discharge information, • Obtain consent for voluntary admissions from the surrogate for patients who lack decision-making capacity, and • Consider accessing expert consultative resources to prepare more effectively for patient treatment and discharge. The OIG made 10 recommendations related to inclusion of family in inpatient mental health treatment and discharge planning; assessment of decision-making capacity and voluntary admission status; documentation of a patient’s surrogate; provision of a complete diagnostic summary to receiving providers; assignment of a mental health treatment coordinator; release of information processes; inpatient mental health unit voluntary and involuntary admission processes; and access to consultative resources.