Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations of incompletely screening for COVID-19 and treatment of a patient with serious mental illness who presented for same-day care at the Michael E. DeBakey VA Medical Center (facility). The OIG substantiated that facility staff did not complete the patient’s COVID-19 temperature screening. The OIG substantiated that facility staff failed to medically manage the patient with COVID-19 symptoms, sent the patient to the drive-through testing area without medical evaluation, and did not isolate the patient, complete a plan of care, or follow policy for transporting patients suspected to have COVID-19. The vulnerable patient disappeared while in the facility’s care, was found off-site four days later experiencing a medical emergency, taken back to the facility, and died the following day. The OIG determined that the Mental Health Intensive Case Management team failed to address documentation discrepancies related to the patient’s surrogate and educate the family on COVID-19 visitor policy and screening processes. The OIG identified the facility’s noncompliance with the missing patient policy, and facility leaders’ failure to report an adverse event and to ensure a timely review of the patient’s episode of care. The OIG identified that facility leaders did not timely or accurately disclose to the patient’s family the medical mismanagement that led to the patient’s adverse clinical outcome. The OIG concluded the failure to screen, isolate, and evaluate the patient resulted in potential COVID-19 exposure to staff, patients, and the public when the patient moved through facility grounds. The OIG made nine recommendations to the Facility Director related to COVID-19 screening, the visitor policy for patients requiring mental health support, identification of patients’ surrogates, mental health care coordination, missing and at-risk patients, adverse event reporting, issue briefs, root cause analyses, and institutional disclosures.