Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana

The VA Office of Inspector General (OIG) evaluated facility compliance with Veterans Health Administration (VHA) suicide prevention policy at the Overton Brooks VA Medical Center in Shreveport, Louisiana, in the care of two patients, one who died by suicide and one who attempted suicide.

The OIG substantiated that staff failed to comply with VHA policy requirements including
•    completion of suicide risk screening and assessments;
•    documentation of response to Veterans Crisis Line requests in the electronic health record;
•    ensuring a patient had a mental health appointment after a high risk for suicide patient record flag (PRF) placement;
•    inactivation of a high risk for suicide PRF; and
•    completion of chart review and family contact form following a patient’s death by suicide.

The team identified two additional concerns with one-to-one observation staffing for patients at risk for suicide and suicide prevention team staffing. Facility staff failed to follow facility policy, which required that a one-to-one observation staff member have no other responsibilities. Facility staff revised the policy to clarify one-to-one staffing. The OIG expects facility leaders to monitor one-to-one observation staff member assignments for compliance. While facility and VISN leaders recognized the need for more suicide prevention staff, there were delays with posting of, and difficulty recruiting for, vacant suicide prevention positions.

The OIG made one recommendation to the VISN Director related to suicide prevention staff posting and identification of recruitment opportunities and seven recommendations to the Facility Director related to compliance with suicide prevention policy and one-to-one observation staff assignments.

The OIG substantiated that staff failed to comply with VHA policy requirements including
•    completion of suicide risk screening and assessments;
•    documentation of response to Veterans Crisis Line (VCL) requests in the electronic health record;
•    ensuring a patient had a mental health appointment after a high risk for suicide patient record flag (PRF) placement;
•    inactivation of a high risk for suicide PRF; and
•    completion of chart review and family contact form following a patient’s death by suicide.

The team identified two additional concerns with one-to-one observation staffing for patients at risk for suicide and suicide prevention team staffing. Facility staff failed to follow facility policy, which required that a one-to-one observation staff member have no other responsibilities. Facility staff revised the policy to clarify one-to-one staffing. The OIG expects facility leaders to monitor one-to-one observation staff member assignments for compliance. While facility and VISN leaders recognized the need for more suicide prevention staff, there were delays with posting of, and difficulty recruiting for, vacant suicide prevention positions.

The OIG made one recommendation to the VISN Director related to suicide prevention staff posting and identification of recruitment opportunities and seven recommendations to the Facility Director related to compliance with suicide prevention policy and one-to-one observation staff assignments.