Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations regarding staff's failure to follow informed consent and against medical advice (AMA) discharge processes and that staff held a patient on the locked mental health unit involuntarily for 48 hours at the VA Southern Nevada Healthcare System (facility) in Las Vegas. The OIG identified a related concern regarding alignment of a medical center policy (MCP) with Nevada state law and Veterans Health Administration requirements. The patient presented to the Emergency Department requesting assistance with substance withdrawal and was admitted to the locked inpatient mental health unit for management of withdrawal symptoms. The OIG substantiated that staff, lacking a standardized process to follow, failed to have the required informed consent discussion to inform the patient that the unit is locked and treats patients with mental health conditions. Upon admission, the patient complained of the restrictive environment and behavior of fellow patients. After verbally requesting an AMA discharge, the patient agreed to remain. The next day, the patient completed a written AMA request and, in accordance with facility policy, was discharged within 24 hours of the request. However, Nevada law states that any patient voluntarily admitted must be released immediately after filing a written request for discharge. The OIG determined that although staff did not hold the patient involuntarily for 48 hours and followed their AMA discharge policy as written, the policy was inconsistent with state law. The OIG found the Facility Director failed to assign responsibility for ensuring the policy adhered to state laws, as required. This failure provided a gap, which may have led to the MCP not aligning with state law. The OIG made seven recommendations to the Facility Director related to the informed consent discussion process, MCP development process, and staff education on MCPs.