Healthcare Inspection - Alleged Mental Health Access and Treatment Issues at a VA Medical Center

The OIG conducted a review to determine the validity of allegations from a complainant regarding a patient’s care at a VA Medical Center (VAMC). The complainant alleged that: (1)The facility denied the patient emergency admission from an outside community hospital Emergency Department (ED) in the spring of 2010, because it was too late in the day for transfer, and there were not enough available beds; (2) a facility Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) social worker chose not to assist with the desired transfer and failed to advise the complainant of transfer status or problems; (3) once the patient was admitted to a Department of Defense (DoD) hospital which houses a jointly managed DoD/ VAMC acute psychiatry unit, VAMC staff failed to follow up and arrange transfer to their facility; and (4) VA did not properly evaluate or provide treatment options for the patient’s post traumatic stress disorder (PTSD) and VA’s failure to treat and early discharge from the DoD medical center set in motion the patient’s tragic death.” We recommended that the VAMC Director ensure that: (1) Inter-facility MH transfer processes are consistent with facility policies, (2) record keeping of inter-facility communication is appropriately maintained and that internal oversight of after-hours admissions, dispositions, transition of responsibility and inter-facility communication is implemented, and (3) MHEC operating hours and staffing in relation to relevant factors, including the frequency and timing of admissions to inpatient MH units is evaluated. The Veterans Integrated Service Network and VAMC Directors concurred with our recommendations and provided an acceptable action plan. We will follow up on the planned actions until they are completed.