Improved Mental Healthcare Demanded After Four Deaths at Atlanta VAMC

by U.S. Medicine

June 8, 2013

By Annette M. Boyle

ATLANTA — Multiple mental health-related deaths at the Atlanta VAMC have led to bipartisan demands from Congress that care and leadership issues be urgently resolved at the facility.

In the wake of a patient death and anonymous tips, the VA’s Office of the Inspector General conducted two audits at the Atlanta VAMC and released the results in April. During the IG investigation, two additional deaths were uncovered.

In response to the audit findings, Rep. Jeff Miller (R-FL), chairman of the House Committee on Veterans’ Affairs, joined members of the Georgia congressional delegation in a tour of the center in early May.

Rep. Jeff Miller (R-FL), chairman of the House Committee on Veterans’ Affairs, second left, and Rep. David Scott (D-GA), right, called for changes at the Atlanta VAMC. They are shown here at a site visit with other members of the Georgia congressional delegation. Photo from Facebook site of Rep. Paul Broun (R-GA)

Shortly after the visit, news of a fourth death surfaced, leading Miller to say, “Clearly, the Atlanta VAMC has serious leadership issues that need immediate outside attention from the highest levels of the department.”

While touring the Atlanta VAMC, Miller said he asked whether there were any other deaths to report and was assured there were not. Three days later, the fourth death, which occurred in November 2012, was confirmed.

While the VA IG investigated the suicide of veteran Joseph Petit on Nov. 9, 2012, it noted that the event did not occur during its site visits on July 23-26, 2012, Sept. 26-27, 2012, and Feb. 26-28, 2013, and therefore was not included in the two audits.

Miller said, however, that the failure to disclose this death “shattered” his confidence in the Atlanta VA leadership. Referring to the media coverage of the deaths, he noted in a statement provided to U.S. Medicine, “If this is what it takes for VA leaders to be honest with Congress about what’s happening at their facilities, you can’t help but question how they operate when they think no one is paying attention.”

Outrage over the news of the November death extended to both sides of the political aisle. Rep. David Scott (D-GA), who also participated in the tour of the facility in May, called for the resignations of VAMC officials as well as action by VA Secretary Eric Shinseki to clean up the mental health and leadership issues at the Atlanta VAMC.

The VA said that, unrelated to the recent controversies, Leslie Wiggins, currently deputy assistant secretary for labor management relations, would take over as director of the Atlanta VAMC, which has been headed by an interim director since December. Scott said in a statement that he “[looked]forward to meeting with Leslie Wiggins to hear about her plan to right the ship at the Atlanta (VA) Medical Center.” 

Anonymous Call

The investigation into the Atlanta VA’s management of a mental health (MH) patient care contract began with an anonymous call to the OIG Hotline Division. The resulting audit uncovered extensive financial mismanagement of the contract with the DeKalb County, GA, Community Service Board (CSB) — and two deaths of mental health patients who “fell through the cracks.”

According to the IG audits, the initial death occurred as a result of an overdose. A suicidal patient with history of substance abuse, left unmonitored at an ophthalmology appointment for several hours, took alprazolam brought in by a visitor. When asked for a urine sample for a drug screen, he provided one, which tested negative. After his death, another patient admitted to providing the urine for the screen. 

One of the two additional deaths reported in the audit occurred as the result of a drug overdose, while the other was ruled a suicide. Here are the details:

●     A patient with a history of suicidal behavior called the Veterans Crisis Line with suicidal ideation and was referred for an evaluation. Ten days later, he had a complete mental health intake evaluation by a psychiatrist, during which time he expressed no intent to harm himself. He was instructed to contact DeKalb CSB and continue taking medications prescribed by a private psychiatrist. His CSB appointment, initially scheduled for Day 93, shifted to Day 107 at the patient’s request. He failed to show for the appointment. Day 206 he reported feeling depressed to his primary care provider. Two weeks later, he died of a drug overdose.

●     Another patient with an extensive history of mental health issues and suicidal behavior was prescribed medication for depression and referred to the DeKalb CSB for consultation. Three weeks later, he told the Healthcare for Homeless Veterans that he still had no appointment with the CSB and felt depressed and suicidal. Healthcare for Homeless Veterans’ psychiatrist was unable to see the patient and directed staff to send him to the Emergency Department via public transportation. He did not go to the ED. The following day, he committed suicide.

As for the November death not included in the IG report, other media have reported that Petit, who suffered from chronic pain and documented mental health issues, took a van to the VA and presented to the veterans hospital emergency department, saying he was hearing voices and was afraid he would hurt his mother. ED staff sent him to his regular psychiatrist and the patient was released later that day. His body was discovered in a staff bathroom in his wheelchair with a bag over his head the following morning.

The VA IG’s office, which noted it had no inspectors on site at the time but sent staff to interview first responders and VA medical personnel, said an autopsy concluded Petit died from suicide.


Safety Issues

The audit on inpatient mental health services found that mental health service line policies did not sufficiently address safety issues and that the facility failed to monitor patients adequately. In addition, the unit lacked adequate policies or practices for contraband, visitation, drug screening or provider notification of clinical changes in a patient’s condition. Also, escort policies were found to inadequately address the needs of the unit’s patients, frequently leaving mental health patients unsupervised and unmonitored when they went for appointments off the unit.

The OIG also found reason to doubt the credibility of staff documentation of patient observation. Despite evidence that the initial patient who died had been unmonitored, flowsheets indicated that staff observed him every 30 minutes and offered him dinner half an hour before his return to the unit.

The audit did not attribute the problems to understaffing.  Based on a time study focused on observation and monitoring, however, the unit hired additional nursing assistants during the investigation and limited the inpatient census to permit unit staff to escort patients to off-unit appointments.

Overall, the IG report “identified inadequate program oversight including a lack of appropriate follow-up actions by leadership in response to patient incidents” and a lack of confidence in management on the part of staff.

In terms of outpatient care, the audit found that mental health service line (MHSL) managers failed to oversee or monitor contracted patient care services effectively and that the program lacked a CSB-specific quality control process. In addition, patient complaints went untracked, and program managers did not conduct oversight visits to CSB sites, as required by VA directives and the contract.

As of July 2012, the Atlanta VA reported 25 patients on the waiting list for the facility’s own mental health unit and 372 patients on the waiting list for CSB mental health treatment. The VA had no established process to verify that a patient had attended an initial CSB appointment or to track what happened with patients after referral, according to the audit.

The OIG reported that 21% of CSB-referred patients received no treatment from the CSB or the VA facility. This was due in part to a failure to provide “adequate staff, training, resources, support or guidance for effective oversight of the contracted [mental  health] program. MHSL managers and staff voiced numerous concerns including challenges in program oversight, inadequate clinical monitoring, staff burnout, and compromised patient safety.”

In 2012, a VA Central Office report noted that the mental health unit had 66.25 full-time staff vacancies, which the report attributed to a lack of space and noncompetitive salaries for psychiatrists.

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