Report Summary

Title: Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center
Report Number: 19-07507-214 Download
Issue Date: 7/28/2020
City/State: Washington, DC
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 an inspection at the Washington DC VA Medical Center (facility) to assess care provided to a patient six days prior to death by suicide and an allegation that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care.”

The OIG substantiated that the patient died by suicide six days after presenting to the Emergency Department with suicidal ideation and staff failed to complete required suicide prevention planning.

During the 12-hour episode of care, the patient navigated two transitions between the Emergency Department and outpatient Mental Health Clinic and saw seven providers. Lack of collaboration between providers, hand-off process deficiencies, and providers’ failure to read the outpatient psychiatrist’s notes led to a compromised understanding of the patient’s medical needs and a failure to enact the outpatient psychiatrist’s recommended treatment plan.

The OIG substantiated that an Emergency Department physician made a statement to the effect of “[the patient] can go shoot [themself]. I do not care,” which could be considered misconduct and patient abuse. Facility and contracted staff failed to report the behavior and did not receive required annual abuse and neglect policy education.

The Emergency Department physician had a history of verbal misconduct. Despite facility leaders’ awareness by late spring 2019 of physician 2’s inappropriate statement regarding the patient and physician 2’s prior pattern of misconduct, facility leaders did not conduct a formal fact-finding or administrative investigation as required by VA.

The Suicide Prevention Coordinator failed to complete the required suicide behavior report and the Emergency Department did not meet Veteran Health Administration’s requirements for a safe and secure mental health evaluation area.

The OIG made one recommendation to the Veterans Integrated Service Network Director and 10 recommendations to the Facility Director.