Report Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs) at the VA Pittsburgh Healthcare System (facility) in Pennsylvania. During the inspection, the OIG found that the BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.

The OIG identified multiple deficiencies in a BHNP’s assessment and documentation practices including absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed certain antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use. The OIG found adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.

The OIG concluded that the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for fiscal year 2018 through the first half of fiscal year 2021, and safety plan completion for high risk for suicide patients for February 2020 through the first half of fiscal year 2021, without these elements being evaluated.

The OIG made five recommendations to the Facility Director related to a comprehensive review of the BHNP’s assessment practices regarding the patient who died by suicide, a review of the BHNP’s overall assessment and documentation practices, alignment of facility policy and leaders’ expectations related to the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed antipsychotic medications, Behavioral Health managers’ verification of BHNPs’ OPPEs review, and a review of managers’ oversight of BHNPs’ OPPEs.