|Title:||Mental Health Emergency Response Documentation Inaccuracy, and Policy and Practice Inconsistencies at the VA San Diego Healthcare System in California|
|City/State:||San Diego, CA
|VA Office:||Veterans Health Administration (VHA)
|Report Author:||Office of Healthcare Inspections
|Report Type:||Hotline Healthcare Inspection
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.