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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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