Review of Care Provided to a Patient Who Died by Suicide and the Subsequent Root Cause Analysis at the Robley Rex VA Medical Center in Louisville, Kentucky

Report Information

Issue Date
Report Number
25-00734-134
VISN
9
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Information Technology and Security
Mental Health
Patient Care Services Operations
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
Information Systems and Innovation
Leadership and Governance
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess clinical and administrative concerns at the Robley Rex VA Medical Center (facility) in Louisville, Kentucky, involving a patient who died by suicide on the grounds of the Carrollton VA Clinic (clinic).

In summer 2024, a patient presented to the clinic requesting reengagement in mental health care. An appointment was scheduled with a psychologist for two days later. The following day, a social worker completed a suicide risk evaluation and safety plan with the patient via telephone. The patient died by suicide the next day while parked at the clinic before the scheduled appointment.

The OIG determined that the social worker did not consider all treatable factors when determining whether to hospitalize the patient and did not ensure that the patient had immediate access to the content of the safety plan, despite documenting that the patient received a copy.

The OIG determined leaders completed a root cause analysis (RCA) that was not credible and did not ensure adequate training and oversight of the interim patient safety manager (PSM). The chief of quality provided altered training documentation that erroneously showed that the PSM completed required training that the PSM confirmed was not completed.

The OIG identified concerns related to changing the author of documented assessments in electronic health records, and patient safety managers performing RCA team roles not consistent with VHA guidance.

The OIG made one recommendation to the Under Secretary for Health to evaluate users’ ability to change the author of unsigned notes; one recommendation to the Veterans Integrated Service Network Director to review the patient’s care; and six recommendations to the Facility Director related to safety plans, inconsistencies in guidance documents, accuracy of electronic health record documentation, RCA processes and completion, PSM training, and altering documentation.
 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director conducts a comprehensive review of the care provided to the patient prior to the event, and takes action as indicated.

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

The Robley Rex VA Medical Center Director ensures that the facility has a mechanism in place for how Veterans Health Administration healthcare professionals will provide content of suicide prevention safety plans when completing suicide prevention safety plans with patients over the phone.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Robley Rex VA Medical Center Director reviews facility Primary Care-Mental Health Integration guidance documents and ensures consistency and alignment with Veterans Health Administration requirements.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Robley Rex VA Medical Center Director reconsiders the practice of reauthoring notes in the Computerized Patient Record System by behavioral health technicians in the Primary Care-Mental Health Integration call center, identifies other facility areas that use the reauthoring process, and takes action as indicated.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates ways to mitigate the implications resulting from users’ ability to change authors in an unsigned note in the Computerized Patient Record System to ensure that such practice is limited to those in roles with a need to have that function, and takes action as indicated.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Robley Rex VA Medical Center Director ensures that root cause analyses are completed in accordance with Veterans Health Administration policy, including root cause analysis process steps, timeliness, and team roles.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Robley Rex VA Medical Center Director ensures that patient safety managers receive oversight, training, and support as required by the Veterans Health Administration.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Robley Rex VA Medical Center Director ensures that the chief of quality understands the seriousness and implications of altering documentation without support, and that leaders, whose actions contributed to the deficiencies outlined in this report, receive administrative action, as appropriate.