Incorrect Use of the Baker Act at the North Florida/South Georgia Veterans Health System in Gainesville, Florida

Report Information

Issue Date
Report Number
23-03677-237
VISN
8
State
Florida
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Mental Health
Patient Safety
Suicide Prevention
VA Police
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the North Florida/South Georgia Veterans Health System to assess an allegation that a patient was “misled” by staff and incorrectly involuntarily admitted to the inpatient mental health unit, and that VA staff actions led to the patient's disengagement from VA mental health care and eventual death by suicide. The OIG reviewed the patient's care in accordance with the Veterans Health Administration (VHA) policy and Florida Mental Health Act (the Baker Act), which provides criteria for involuntary mental health care. The OIG identified deficiencies in staff adherence and leaders’ oversight pertaining to VHA policy and the Baker Act, but was unable to determine whether a change in care would have altered the patient’s outcome.

The OIG substantiated that system staff admitted the patient under involuntary status despite the patient’s request for voluntary admission and that staff incorrectly applied the involuntary inpatient Baker Act examination hold criteria.

The OIG found that during outpatient mental health appointments prior to admission, the patient was not offered evidence-based psychotherapy for posttraumatic stress disorder (PTSD) or informed of available treatment options. The OIG determined that turnover in mental health providers was a contributing factor in the patient's decision to withdraw from mental health care and that despite the patient voicing concerns about being involuntarily admitted, staff did not document a response to the patient’s concerns, likely contributing to feelings of being “misled” by staff.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2025

The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2025

The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025

The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2025

The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2025

The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.