Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee

Report Information

Issue Date
Report Number
19-09493-249
VISN
9
State
Tennessee
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Suicide Prevention
Care Coordination
Major Management Challenges
Healthcare Services
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation that a patient who sought treatment for insomnia and was out of psychiatric medications did not receive the care needed at the Memphis VA Medical Center (facility) in Tennessee. The patient died by suicide the day following a visit to the facility’s Emergency Department. The OIG substantiated that the patient presented to the facility’s Emergency Department for insomnia and psychiatric medication refills. The Emergency Department physician documented evaluating the patient and after a negative screen for suicidal thoughts, discharged the patient with instructions to go to the facility’s Outpatient Mental Health Clinic immediately for medication management. The OIG found no documentation that the patient registered or received treatment in the clinic. The OIG found the patient did not receive the care needed and the facility did not have a clear referral process for patients discharged from the Emergency Department who needed to be seen the same day in the Outpatient Mental Health Clinic. The patient received primary care from the facility and mental health care through the community. Several community care counseling sessions were not authorized timely due to deficiencies in coordination of care between the facility’s community care staff, community care providers, and the third party administrator. Facility community care staff did not obtain medical record documentation for community care treatment and did not ensure care authorizations were current, resulting in the patient’s inability to receive several medication refills from the facility pharmacy. Facility leaders were aware of the patient’s death by suicide within three days of the patient’s death; however, the OIG could not find evidence that executive leaders were notified or that the family was contacted. The OIG made 16 recommendations to the Facility Director.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the current process for patients discharged from the Emergency Department who need to be seen the same day in the Outpatient Mental Health Clinic for medication management, establishes a clear referral process to the Outpatient Mental Health Clinic, and verifies that patients receive the care needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director reviews the Emergency Department Mental Health Handbook and defines a clear process for medication management in the Emergency Department, and ensures that patients receive same day psychiatric medication management when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the current process for Emergency Department physicians to refer patients to the Emergency Department mental health provider for a mental health assessment and verifies that patients who require mental health provider assessment receive the care needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director reviews the current medication reconciliation processes in the Emergency Department and Primary Care Clinics and verifies that providers complete and document medication reconciliation in accordance with policy and makes changes as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director assesses the Outpatient Mental Health Clinic check-in process and verifies mental health patients are registered, triaged, and receive mental health services as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center ensures that patients are offered the option of community care consult, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the outpatient consult process and verifies that providers manage discontinued consults appropriately.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the process for community care clinical oversight, clarifies who has responsibility for coordinating care for patients receiving mental health in the community, and verifies that patients receive authorized community mental health care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the process for timely retrieval of medical records from community care providers, verifies the medical records are uploaded into patients’ electronic health records, and takes action as necessary.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director evaluates the clinical review process for community care authorizations, ensures staff are trained on the process, verifies that authorizations have clinical delegate review, and are processed timely.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director reviews the complaint reporting, responding and tracking processes and ensures that complaints are addressed, resolved, and documented in accordance with current facility policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director ensures leaders and supervisors are trained on initiating and conducting a fact finding.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director considers conducting further review to address the differing accounts of the Emergency Department physician and Emergency Department mental health provider regarding the patient referral to ascertain whether the Emergency Department failed to follow facility policy, and takes action if needed.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director ensures that responsible staff receive training on completing behavioral autopsy reports as required by the Veterans Health Administration Behavioral Health Autopsy Program and verifies that behavioral autopsies are completed in accordance with policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director reviews the issue brief reporting requirements with supervisors and ensures timely issue brief reporting for patients who die by suicide.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Memphis VA Medical Center Director ensures that staff who conduct root cause analyses are trained on the guidelines for interviewing individuals vital to the root cause analysis charter and identified processes, and verifies the root cause analysis interview guidelines are followed.