Healthcare Inspection Attempted Suicide During Treatment West Palm Beach VA Medical Center, West Palm Beach, Florida

OIG performed an inspection at the West Palm Beach VA Medical Center, West Palm Beach, FL, to determine the validity of allegations regarding a high-risk patient attempting suicide in the emergency department and again on the mental health unit. The complainant also expressed concerns about staff training; poor communication with the family; staff actions regarding an art therapy class; and the patient’s transfer to a non-VA treatment center. OIG substantiated that due to lapses in carrying out suicide safety measures, the patient was able to attempt suicide twice while under the care of facility providers. While not part of the allegations, we found that the facility’s internal reviews of the events did not fully adhere to the National Center for Patient Safety guidelines for completion of root cause analysis. Two of the complainant’s allegations resulted in recommendations to the VISN and Medical Center Directors.