OIG Cites Minnesota VA Hospital for Failure to Prevent Veteran’s Suicide
A recently released report from the Office of Inspector General (OIG) disclosed that a Minnesota Veterans Affairs (VA) hospital had been cited for the second time in two years for its failure to prevent a veteran’s suicide.
When the veteran visited the hospital’s emergency room, he was experiencing withdrawal symptoms due to opioid and benzodiazepine addiction. After expressing thoughts of suicide and homicide, he was admitted.
The veteran continued to verbally express his desire to end his life by saying, “I want to die,” to a dietitian, a chaplain, and a medical resident. In a phone conversation overheard by a nurse, he talked about his impending death and gave away his personal possessions. A couple of hours after that call, the veteran disappeared, and staff members were unable to locate him. The hospital later received notification from an offsite emergency room that the veteran had killed himself.
The dietitian, chaplain, and the nurse were all cited for failing to notify a physician about the veteran’s suicidal speech and behavior. The OIG cited the hospital for failing to notify the facility’s suicide prevention coordinator about admitting a patient with suicidal ideations. Also, the medical resident was cited for not properly reviewing notes about the veteran’s suicidal expressions.
Although the VA hospital was cited for these failures, no single issue or combination of issues were determined to be the cause of the veteran’s death by the investigating team.
The report did note that the rate of suicide by veterans is significantly greater than that of U.S. civilian adult males. The rate for veterans is 37.2 per 100,000 compared to 25 per 100,000 for civilian adult males. In 2014, the number of veteran deaths by suicide averaged 20 a day, according to the Veterans Health Administration.
In response to the OIG report, the hospital now has a suicide program manager and is providing additional training regarding suicide ideation for staff members.
Compliance Perspective
Failure by staff to ensure that residents who verbally express suicidal ideation at any time and exhibit classic suicidal behavior, like giving away personal possessions and expressing a feeling of impending death, may be considered substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures for evaluation at the time of admission and throughout a resident’s stay for suicide and trauma risks.
- Train staff about risk factors and warning signs that may indicate the presence of suicidal ideation and the need for prevention and intervention plans and a trauma-informed care approach.
- Periodically audit to determine if residents who are at risk for suicide and/or have experienced traumatic events are receiving trauma-informed care and have care plans that include suicide prevention and intervention procedures.
