Inadequate Care Coordination for a Mental Health Residential Rehabilitation Treatment Program Resident in VISN 20, Oregon

The VA Office of Inspector General (OIG) conducted an inspection at the Southern Oregon Rehabilitation Center and Clinics in White City (facility) and Roseburg VA Health Care System (Roseburg) in Oregon to evaluate an allegation that a resident (resident 1) was admitted to the facility’s Mental Health Residential Rehabilitation Treatment Program (MH RRTP) despite not meeting admission criteria, was later transported to Roseburg for admission but was instead discharged to the community. Additional allegations were received that a second resident did not meet admission criteria and another resident was injured in the shower area. The OIG later learned about other residents who may not have met admission criteria and who fell in the shower area. The OIG did not substantiate that resident 1 was inappropriately admitted to the MH RRTP but found the resident’s discharge was not coordinated. The OIG determined the resident’s transport to Roseburg did not comply with policy. Resident 1 was assessed, determined to not meet Roseburg admission criteria, and discharged to the community. The OIG found that four of five residents reviewed met admission criteria. The OIG was unable to determine if the fifth resident met admission criteria, but found the resident should have been reevaluated after a change in medical status prior to admission. The OIG substantiated a resident was injured after falling while getting out of the shower and learned about two additional residents who fell in the shower area in the preceding 10 months. The OIG determined that facility leaders were aware of the falls but missed an opportunity to implement solutions in a timely manner. The OIG made five recommendations to the Facility Director related to the discharge template, discharges during regular business hours, transport of residents with behavioral flags, conducting medical evaluations, and a review of falls in the shower area.