Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri
Report Information
Summary
The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.
The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.
The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.
The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.
The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.
The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.