Patient suicide linked to safety issues at Florida VA hospital, OIG finds

Seniors leaders failed to promptly address "long-standing deficient conditions" and safety concerns at West Palm Beach VA Medical Center, which may have contributed to a patient's suicide in early 2019, according to an Aug. 22 report from the VA Office of Inspector General.

OIG inspected the Riviera Beach, Fla.-based hospital after the incident and found the patient received "reasonable care" while admitted to the facility's locked inpatient mental health unit. However, investigators found numerous deficiencies in staffing, employee training and risk mitigation on the unit. Cameras the hospital was required to have on the unit for patient safety reasons hadn't worked in three years. In addition, staff members failed to properly conduct the required safety checks every 15 minutes on admitted patients, inspectors found.

"Overall, the OIG found that facility leaders lacked awareness of patient safety requirements and related issues on unit 3C and appeared to accept inaccurate explanations for noncompliance and unsafe conditions," OIG wrote.

The medical center completed a "thorough review" of its mental health unit after the incident and is implementing a corrective plan based on nine recommendations from the OIG, according to Miguel LaPuz, MD, director of the St. Petersburg, Fla.-based VA Sunshine Healthcare Network.

"We appreciate the Office of Inspector General's oversight, which focuses on an event that occurred in March 2019," the VA said in a statement to Becker's. "Any time an unexpected death occurs at a VA facility, a comprehensive review is conducted to see if changes in policies and procedures are warranted. OIG reviews are opportunities to strengthen our processes and the way we deliver care to America's veterans."

"Additionally, we continue to reinforce education to all staff and maintain suicide prevention as a priority. As part of our ongoing structural improvement plan, we continue to make upgrades to all areas of the hospital to provide the safest environment for our patients, visitors and staff," the VA said.

Editor's note: This article was updated Aug. 23 at 1:05 p.m. to include additional information from tha VA.

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