Report Summary

Title: Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida
Report Number: 19-07429-195 Download
Issue Date: 8/22/2019
City/State: West Palm Beach, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection, in response to a notification that a hospitalized patient died by suicide and a subsequent request from House Veterans Affairs Committee Chairman Mark Takano, to review the circumstances of the death.

Inpatient death by suicide is an event that is largely preventable. The OIG determined the patient received reasonable care during the admission. The patient was appropriately screened for suicide risk, provided medication management, placed on close observation status, and had on-going assessments, interventions, and a discharge plan. However, the facility failed to abate identified safety hazards on the unit. Patient safety cameras were nonoperational and 15 minute patient safety rounds policy lacked clear guidance and expectations for staff. The facility did not meet Veterans Health Administration (VHA) requirements for staffing an Interdisciplinary Safety Inspection Team or training staff regarding the Mental Health Environment of Care Checklist (MHEOCC). The OIG found a lack of oversight by both the VHA MHEOCC Work Group and Veterans Integrated Service Network (VISN) 8. The OIG also found facility leaders lacked awareness and failed to educate themselves on patient safety requirements regarding the mental health unit.

While the OIG team determined the facility responded promptly to the adverse patient event and was in the process of implementing improvement actions, facility leaders and managers only started to respond aggressively to long-standing deficient conditions after a sentinel event occurred. The OIG made one recommendation to the Under Secretary for Health, one recommendation to the VISN Director, and nine recommendations to the Facility Director related to leaders’ responsibilities regarding mental health, environment of care, and patient safety; MHEOCC training; risk mitigation; facility policy regarding patient safety and law enforcement cameras on the locked mental health unit; 15-minute safety rounding policy; and staff training.