Deficiencies in Administrative Actions for a Patient’s Inpatient Mental Health Unit and Community Living Center Admissions at the Tuscaloosa VA Medical Center in Alabama

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate. The inspection also evaluated OIG-identified concerns related to Inpatient Mental Health Unit and Community Living Center (CLC) staff’s administrative actions during the patient’s admissions. The OIG substantiated that staff denied the patient’s discharge requests. The OIG found that staff failed to follow informed consent procedures. The OIG also found that staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record. The patient remained on voluntary status during Inpatient Mental Health Unit and CLC admissions for nearly 2 years and 11 months. Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions. The OIG found that staff did not comply with requirements when the patient requested an against medical advice discharge. The OIG also determined that staff did not properly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker. The OIG substantiated that staff failed to ensure the patient’s access to the patient advocate. Staff did not properly manage a letter from the patient that was intended for a public official. The OIG made seven recommendations to the Facility Director related to informed treatment consent processes, decision-making capacity evaluation completion and documentation, commitment requirements, against medical advice discharge procedures, surrogate decision-maker assignment, patient advocate reporting and tracking processes, and management of the patient’s correspondence request.