Report Summary

The VA Office of Inspector General (OIG) assessed allegations that San Diego VA Medical Center (facility) staff provided an inadequate evaluation of cognitive functioning, suicide risk, grave disability, and care coordination for a patient who died approximately six hours after leaving the facility. The OIG also evaluated a concern about mental health emergency response (code green) policy and practice inconsistencies.

In early 2022, facility police officers (Officers 1 and 2) responded to a report that the patient “was loitering.” The patient denied needing assistance and planned to remain on VA property overnight. The patient made threatening statements after being told the patient’s vehicle would be towed due to a suspended vehicle registration and the patient not having a valid drivers’ license. Officer 2 escorted the patient to the Emergency Department, and a nurse called a code green.

The code green team resident physician determined that the patient did not meet criteria for a psychiatric hold. Officer 2 provided the patient with transportation options. Later the Officers saw the patient, who refused to check in to the Emergency Department. The Officers walked the patient off VA property. Approximately six hours later, the patient’s death was reported to the Medical Examiner’s Office after an interstate driver reported having struck the patient.

The OIG did not substantiate that facility staff failed to adequately evaluate the patient’s cognitive functioning, suicide risk, and grave disability. The OIG substantiated that staff failed to coordinate the patient’s care. The code green team leader inaccurately documented having “passed care.” The OIG concluded that staff appropriately respected the patient’s right to decline care when the patient later refused services.

The OIG found inconsistencies between policy and practice in the patient’s code green event.

The OIG made two recommendations to the Facility Director related to code green documentation and policy.