Safety Issues Alleged to Have Contributed to Patient’s Suicide in Florida VA Hospital
During a recent inspection of a Florida VA hospital after a patient committed suicide, the Office of Inspector General (OIG) found numerous serious safety concerns. The investigators found that while the patient was provided “reasonable care” in the facility’s locked mental health unit, there were substantial deficiencies in staffing, employee training, and mitigation of identified safety risks on the unit.
One deficiency noted in the investigators report regarded the requirement that the unit must have cameras for patient safety reasons, and while there were cameras in place, they had not been operational for at least three years. Another deficiency reported was the failure by staff members to conduct required safety checks on the unit’s patients every 15 minutes.
The report included this statement: “Overall, the OIG found that facility leaders lacked awareness of patient safety requirements and related issues on the mental health unit and appeared to accept inaccurate explanations for noncompliance and unsafe conditions.”
The VA hospital is implementing a corrective plan based on nine recommendations from the OIG report.
Risk Assessment Perspective
Failure by a facility to identify and mitigate risks to patients in a secured mental health unit that includes scheduling an adequate number of staff to perform the required 15-minute checks on the patients in the unit, providing employee training that includes suicide and suicide ideation prevention and intervention, and maintaining and monitoring the unit’s required cameras, may be considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding risk assessment and mitigation of safety issues in all patient units, and determine their adequacy for mental health and other secured units where more frequent monitoring may be needed.
- Train staff about the importance of monitoring patients requiring 15-minute or other frequent checks, intervention and prevention of suicide and suicide ideation, and mitigating identified safety risks.
- Periodically audit to ensure that patients are receiving required 15-minute or other frequency checks, that cameras are working, and that a sufficient number of staff are scheduled.
