Review of a Patient’s Discharge from the Central Virginia VA Health Care System in Richmond

The VA Office of Inspector General (OIG) initiated a healthcare inspection of the Central Virginia VA Health Care System (system) in Richmond on November 24, 2025, to evaluate allegations that staff did not arrange a patient’s safe discharge from the inpatient mental health unit. The OIG also assessed concerns with post-discharge care.

The OIG substantiated that a psychiatrist and social worker did not facilitate a safe discharge as the patient’s needs exceeded what the spouse could manage. Although the treatment team initially recommended a higher level of care, multiple nursing homes rejected the patient due to behavioral issues. The psychiatrist planned to discharge the patient home with support services. Despite the spouse’s concerns, neither the psychiatrist nor the social worker evaluated the safety of the discharge plan. 

The OIG determined the patient advocate did not follow required procedures when addressing the spouse’s concerns about the patient’s discharge plan. The OIG also found the psychiatrist and pharmacist did not ensure medication reconciliation was completed at discharge and during post-discharge calls. 

Outpatient staff did not address concerns of abuse during post-discharge calls as required, and the timely reporting of suspected non-imminent abuse may not have occurred as Veterans Crisis Line procedures only allow for a routine referral, which may delay review until the next business day. 

The OIG made six recommendations, one to the Under Secretary for Health and five to the System Director. The Under Secretary for Health nonconcurred with the recommendation to consider establishing a process to timely escalate concerns of non‑imminent abuse. The five recommendations to the System Director were related to discharge, patient advocacy, medication reconciliation, reporting abuse, and a review of the patient’s care. The System Director concurred with these recommendations and provided acceptable action plans. The OIG closed two recommendations prior to publication.