Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of inadequate clinical care of a patient who died by suicide on the inpatient medical unit.

In summer 2023, a physician admitted the patient to the facility’s medical unit, placed an order for one-to-one observation status (1:1) for suicidal ideation, started a Clinical Institute Withdrawal Assessment of Alcohol Revised (CIWA-Ar) protocol for treatment of alcohol withdrawal symptoms, and entered a consult to the psychiatry service. Four days later, the patient was found in the bathroom hanging from a necklace, having died by suicide.

The OIG found that staff did not follow policy requirements to remove the patient’s belongings or reduce environmental risks. Additionally, a nurse failed to conduct a warm handoff as required for the completion of a Comprehensive Suicide Risk Evaluation (CSRE) after completing a positive suicide risk screening. The psychiatrist completed a telemental health evaluation of the patient but did not complete the required CSRE. On the third day of admission, the psychiatrist did not reassess the patient before changing the patient’s 1:1 order to every 15-minute checks and did not sign the evaluation note within the required 24-hour time frame, leaving the assessment unavailable to other providers.

Nursing staff documented CIWA-Ar assessments every 1–4 hours and administered lorazepam as ordered except for one error. The medical unit nurse manager reported addressing the error, and the error had no impact on the patient’s outcome.

Facility leaders evaluated processes related to the care of the patient through actions that included a root cause analysis in accordance with Veterans Health Administration policy. The resulting action plans addressed concerns identified in this report.

The OIG made four recommendations to the Facility Director related to clinical screenings and evaluations, timely documentation, and removing environmental risks.