Deficiencies in Quality of Care at VA Maine Healthcare System in Augusta

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to deficiencies in the communication with and care coordination for a post-stroke patient who died by suicide at the VA Maine Healthcare System (facility) outpatient clinic in Augusta, Maine. Although the OIG identified deficiencies in the quality of care and completion of quality reviews, the OIG was unable to determine whether a change in care would have resulted in a different outcome for the patient. After the patient had a stroke, facility staff communicated with the patient and scheduled a primary care appointment. However, following the patient’s suicidal statements, facility staff were unable to engage the patient to complete a formal suicide risk screening and did not document the inability to complete the screening per Veterans Health Administration policy or ensure a safety plan was in place. Furthermore, a staff member did not follow the facility policy of notifying suicide prevention staff to garner support for the patient. A primary care provider failed to assess the patient for post-stroke depression, conduct a neurological assessment to determine cognitive or neurological impairments, or consider all options for rehabilitation services and transportation to outpatient therapy. The OIG identified deficiencies with facility quality management reviews. The root cause analysis team did not follow the required process for facility leaders’ nonconcurrence with root cause analysis findings. Additionally, facility leaders did not recognize the need to conduct a peer review of the primary care provider as required by VHA policy. The OIG made seven recommendations to the Facility Director related to suicide screening, safety plans, suicide prevention staff engagement, root cause analyses, peer reviews, and quality management reviews.