Deficiencies in Community Living Center Practices and the Death of a Patient Following Elopement from the Chillicothe VA Medical Center in Ohio

The VA Office of Inspector General (OIG) conducted a review to assess aspects of the care provided to a patient who was struck and killed by a motor vehicle following elopement from a community living center (CLC). The patient suffered from paranoid schizophrenia and was involuntarily civilly committed to the CLC. The OIG had concerns regarding the appropriateness of CLC admission and elopement prevention. The OIG determined that the patient’s admission to the CLC was inappropriate as indicated by the CLC’s own screening process. The OIG determined that interventions implemented by staff were inadequate to mitigate the patient’s risk for elopement. The patient eloped multiple times and facility staff failed to provide individualized, progressive, mental health-driven interventions to prevent the patient from eloping. The OIG also found that facility staff assigned to care for the patient were inadequately trained in mental health care, and patient safety reports were not completed as required. On the day of the patient’s death, the OIG found that facility staff did not follow missing patient procedures after the patient eloped. Facility staff failed to detect that the patient was missing for nearly three hours and once the patient was noted as missing, facility staff failed to follow policy to locate the patient. In addition, the OIG found that facility leaders did not ensure the facility had a missing patient prevention policy or that staff completed annual missing patient training. The OIG expressed concern that the CLC may not have been utilized as intended, given the lack of mental health standards applicable to CLCs and the complex mental health needs of this patient. The OIG made 12 recommendations to the Veterans Integrated Service Network and Facility Directors regarding reviews of the patient’s care, the use of the CLC, and staff training.