Quality of Care and Patient Safety Concerns on the Acute Behavioral Health Unit at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review quality of care and patient safety concerns identified by an OIG medical consultant after providing assistance during an OIG Office of Investigations inquiry into an unexpected patient death at the facility. The OIG determined that quality of care deficiencies may have contributed to a patient’s death during the Unit 7E admission. Unit 7E providers did not monitor the patient for electrocardiogram changes or drug-drug interactions. Staff and providers documented signs consistent with oversedation, but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record. The facility did not comply with Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews. Unit 7E staff did not follow the facility’s observation policy. Facility providers did not adhere to policies requiring discussion, documentation, and a patient signed informed consents prior to initiating methadone treatment. Leaders implemented measures to address deficiencies including equipment issues identified by the rapid response team and training needs to mitigate the potential for future patient safety events. The OIG made nine recommendations related to monitoring patient care and communication; compliance with review requirements, observation policy, and signed consent; and monitoring of findings and action plans.