Healthcare Inspection Follow-Up Evaluation of Veterans Health Administration Missing Patient Policies and Procedures

This review follows up on an OIG report entitled Evaluation of Veterans Health Administration Missing Patient Policies and Procedures, report number 00-00282-12, dated November 30, 2000. In that report, we made multiple recommendations to improve the safety of patients at risk for wandering or elopement. In response, Veterans Health Administration (VHA) implemented new policies and enhanced procedures. A representative sample of 200 missing patient events occurring in FY 2009 reflected that VHA facilities were following up on missing patients and documenting the outcomes of those efforts, and that staff were reporting missing patient events in accordance with guidelines. VHA has also shown substantial improvement in the areas of elopement/wandering risk assessment and implementation of safety measures; however, additional actions were needed related to applying assessment criteria, timing of assessments, documenting proactive and concurrent safety measures, and placing Patient Record Flags. We also found that VHA Directive 2008-057 provides confusing guidance related to the timing of risk assessments, and that local policies didn’t always comply with other requirements as outlined in the Directive. The Under Secretary for Health agreed with the findings and conclusions and provided acceptable improvement plans.