The investigation, conducted by the Veterans Affairs Office of the Inspector General, started in late August 2017.
The patient who died, a man in his 60s, fell from the bathroom window of his second-story room in the acute medicine unit, according to the OIG report released Sept. 12.
A VA physician initially said the death was a suicide, but further investigation found the man, who had a history of mental health conditions, had been agitated about being under constant observation and had opened the window several days before.
The report found the “external windows on the inpatient medicine unit were not secured shut or limited in width of opening as required” by policy, and numerous staff members did not finish required training for preventing these behaviors. It also determined the VA failed to try to notify the patient’s child of his father’s death.
Chillicothe VA Director Mark Murdock said the VA is rectifying the issues by securing windows in the acute medicine unit, ensuring window checks twice a year and requiring nurse managers to ensure proper staff training is occurring.
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