Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas

The VA Office of Inspector General (OIG) assessed allegations that a patient died by suicide the day of discharge from the Inpatient Mental Health Unit, and that facility leaders failed to complete an institutional disclosure. The patient, who was over 70 years old at the time of death, had diagnoses that included posttraumatic stress disorder and major depression. After approximately 15 years of care at a California VA facility, the patient transferred care to the facility in summer 2019. The OIG substantiated that the patient died by suicide the day of discharge. In summer 2019, outpatient providers did not complete required comprehensive evaluations with the patient. The emergency department social worker documented an incomplete comprehensive evaluation. The suicide prevention team did not assign the patient a high risk for suicide patient record flag in spite of the patient’s stressors and history of suicide behaviors. Staff did not adequately assess the patient’s substance use, incorporate relevant history into the treatment plan, or address the patient’s change in demeanor and concerning statements. The discharge safety plan had not been modified for approximately eight months in spite of significant life changes. Leaders had not established a mental health treatment coordinator (MHTC) policy. Staff assigned the patient an MHTC at the patient’s tenth visit and four MHTCs over nine months. Staff did not coordinate care with a geropsychologist, with whom the patient had nine appointments. Leaders did not effectively address the patient’s expressed complaints. The OIG substantiated that leaders did not conduct an institutional disclosure. The OIG made 10 recommendations related to evaluation of suicide risk and substance use disorder, incorporation of critical information into treatment and discharge planning, MHTC policy, discharge coordination, patient complaint response, identification of sentinel events, and an institutional disclosure for the patient’s care.