Review of Quality of Care for Patients Seeking Acute Mental Health Care at the Lexington VA Healthcare System in Kentucky

Report Information

Issue Date
Report Number
25-00349-10
VISN
9
State
Kentucky
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Mental Health
Patient Safety
Suicide Prevention
Major Management Challenges
Healthcare Services
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 at the Lexington VA Healthcare System (system) in Kentucky to determine the validity of an allegation that patients seeking or receiving acute mental health treatment did not receive the care needed.

The OIG substantiated quality of care deficiencies for two patients seeking acute mental health treatment at the system. Multiple staff did not recognize one patient’s personally owned insulin pump as a potential lethal means, which allowed the patient to attempt suicide. Following the attempted suicide, leaders did not implement system-wide actions to mitigate the risk associated with insulin pumps for patients who have suicidal ideation. Additionally, a psychiatrist did not provide a second patient with emergency department discharge instructions or document care in the electronic health record (EHR) consistent with Veterans Health Administration (VHA) policy. The psychiatrist’s documentation included copied and pasted information and a derogatory, critical comment about the patient. 

The OIG determined the System Director and Chief of Staff did not ensure that quality management processes, including safety assessment scoring, a root cause analysis, and peer review, were conducted accurately and completely to address system vulnerabilities and patient safety risks for two patients.

The System Director concurred with and provided action plans for the OIG’s eight recommendations related to personally owned insulin pumps, an insulin pump policy, compliance with discharge instructions, review of a psychiatrist’s EHR entries, accuracy of safety assessment code scores, education on root cause analysis processes, and psychiatrist peer representation at the system Peer Review Committee for psychiatry case reviews. The OIG also published a separate report with one recommendation to the Under Secretary for Health to consider specific VHA guidance related to personally owned insulin pumps as a lethal means when patients are deemed at risk for suicide.

 

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 Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.

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

The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.

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

The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.

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

The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.

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

The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2’s documentation in Patient 2’s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.

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

The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.

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

The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.

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

The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.