Healthcare Inspection: Service Delivery and Follow-up After a Patient's Suicide Attempt Minneapolis VA Health Care System Minneapolis, Minnesota.

摘要

The VA Office of Inspector General Office of Healthcare Inspections conducted a review at the request of Congressman Tim Walz regarding alleged improper medication management and discharge planning practices at the Minneapolis VA Health Care System (the facility) in Minneapolis, MN. We did not substantiate the complainants allegations that a change in medication contributed to her husbands death by suicide, that managers improperly tried to commit him to a Veterans Home, or that staff told her she was not her husbands power of attorney (POA). Medical record documentation reflects that the patients medication had not been changed. His chronic depression was attributed to his medical and mental health conditions and to his substantial psychosocial stressors. Further, the medical record does not support the allegations related to the Veterans Home or POA. We found, however, that the Suicide Prevention Coordinator did not participate in the evaluation and ongoing monitoring of the patient, and the treatment team did not complete a suicide risk assessment at the time of the patients discharge in February. Staff did not place the patient on the high-risk for suicide list or initiate a patient record flag (PRF), and as a result, the patient did not receive the prescribed level of monitoring and follow-up. Clinical staff did not complete a suicide behavior report or report the patients death by suicide in a reasonable time. The former patient safety manager learned of the suicide more than 2 weeks after the event.