Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California

The VA Office of Inspector General (OIG) evaluated allegations that a patient presented unscheduled to the Chico Community-Based Outpatient Clinic in California (Chico CBOC) and later was involved in a violent incident with family members, and facility leaders did not address employee concerns related to the adverse clinical outcome and mental health staffing. The OIG also identified concerns related to facility staff’s failure to provide same-day access, adequate mental health assessment, mental health triage, medication management, and facility leaders’ failure to consider completing an institutional disclosure and address concerns about the Chico CBOC building design. The OIG substantiated that the patient presented to the Chico CBOC Mental Health Clinic “highly agitated,” “was sent home,” and later had a violent altercation. The OIG did not substantiate that facility leaders failed to address employee concerns regarding staff well-being and inadequate mental health staffing levels. The OIG found that a nurse practitioner did not have same-day availability to evaluate the patient the day of the unscheduled visit. When the patient was unable to engage in a risk assessment, the OIG found that a triage social worker did not document the patient’s risk and protective factors, reasons for the patient’s inability to complete the assessment, or attempt to ask the patient’s family member about risk and protective factors. The OIG found that the nurse practitioner did not align medication management with treatment guidelines, document a comprehensive rationale for medication choices, document medication instructions accurately, or schedule a follow-up appointment within the expected time frame. Following the patient’s adverse clinical outcome, the OIG found that facility leaders did not complete an institutional disclosure. The OIG made five recommendations to the Facility Director related to same-day mental health access, risk assessment documentation, medication management continuity of care, institutional disclosure, and environmental changes to the Chico CBOC.