Incorrect Use of the Baker Act at the North Florida/South Georgia Veterans Health System in Gainesville, Florida

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the North Florida/South Georgia Veterans Health System to assess an allegation that a patient was “misled” by staff and incorrectly involuntarily admitted to the inpatient mental health unit, and that VA staff actions led to the patient's disengagement from VA mental health care and eventual death by suicide. The OIG reviewed the patient's care in accordance with the Veterans Health Administration (VHA) policy and Florida Mental Health Act (the Baker Act), which provides criteria for involuntary mental health care. The OIG identified deficiencies in staff adherence and leaders’ oversight pertaining to VHA policy and the Baker Act, but was unable to determine whether a change in care would have altered the patient’s outcome. The OIG substantiated that system staff admitted the patient under involuntary status despite the patient’s request for voluntary admission and that staff incorrectly applied the involuntary inpatient Baker Act examination hold criteria. The OIG found that during outpatient mental health appointments prior to admission, the patient was not offered evidence-based psychotherapy for posttraumatic stress disorder (PTSD) or informed of available treatment options. The OIG determined that turnover in mental health providers was a contributing factor in the patient's decision to withdraw from mental health care and that despite the patient voicing concerns about being involuntarily admitted, staff did not document a response to the patient’s concerns, likely contributing to feelings of being “misled” by staff.