Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas

The OIG evaluated concerns at the Michael E. DeBakey VA Medical Center (facility) regarding staff’s failure to arrange an evidence-based psychotherapy (EBP) referral for a patient assigned a high risk for suicide patient record flag (high-risk flag). The OIG reviewed concerns that staff did not adequately conduct lethal means safety planning or provide required high-risk flag management for the patient. Although the patient was receiving psychiatric care, the OIG found that staff failed to provide in-person EBP until over a year after the patient’s request, inconsistent with Veterans Health Administration (VHA) requirements. The OIG also found that staff did not offer the patient equipment to participate in virtual sessions or consistently document attempts to contact the patient as required. It was determined that a psychologist and psychiatrist did not sufficiently address the patient’s access to lethal means. Given the patient’s firearm access and past suicidal behavior, the OIG would have expected the psychologist to address the patient’s potential to obtain ammunition and document a discussion of risk reduction strategies. The OIG found that the psychiatrist did not document evaluation of the patient’s access to ammunition. Following high-risk flag initiation, staff did not meet with the patient, document suicide risk assessment, or update or review the patient’s safety plan, as required. Inconsistent with a VHA requirement, an Office of Mental Health and Suicide Prevention leader reported that homeless program staff are not expected to review or update safety plans during high-risk flag follow-up appointments. The OIG made one recommendation to the Under Secretary for Health to clarify requirements for suicide risk assessment completion and safety plan reviews and five recommendations to the Facility Director related to EBP consult management, timely scheduling, and documentation; VA-issued devices; lethal means safety; and high-risk flag follow-up.