Report Summary

Title: Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee
Report Number: 19-09493-249 Download
Issue Date: 9/3/2020
City/State: Memphis, TN
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 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.