Deficiencies in Crisis Management of a Client, Crisis Reporting, and Documentation Practices at the Everett Vet Center in Washington

The OIG evaluated allegations related to (1) the crisis management of a client at the Everett Vet Center; (2) documentation added to the client’s clinical record by district 5, zone 1 (district) and Everett Vet Center leaders to justify lack of action; and (3) altered notes. The OIG reviewed concerns regarding clinical documentation, safety planning, and the Vet Center Director’s (VCD’s) clinical consultation to staff.

The OIG substantiated that Everett Vet Center staff and leaders inadequately managed the client’s crisis because the VCD advised a counselor to allow the client to leave the clinic without notifying law enforcement authorities. The OIG also substantiated that the VCD and counselor failed to seek consultation from the support facility’s external consultant or follow up with the support facility’s suicide prevention team. The counselor did not update the client’s safety plan when the client presented to the appointment with increased risk.

The OIG found that the VCD backdated a progress note due to lack of awareness of documentation requirements and a district leader deleted progress notes; however, at the time, staff and leaders had the capability to delete notes and did so under certain circumstances. The counselor delayed crisis reporting due to uncertainty about whether the client’s circumstances met the criteria for reporting the event. 

The OIG found that conflicting information regarding the scope of the VCD’s clinical responsibilities may have contributed to the VCD’s failure to consult immediately with a district leader on the day of the client’s visit.

The OIG made four Readjustment Counseling Service-level recommendations on crisis reporting and monitoring, clinical record and risk assessment documentation, and VCD position descriptions; and five district-level recommendations related to  reviews of care; duty-to-warn obligations; consultation with external consultants and suicide prevention coordinators; and safety planning.