Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA Health Care System, Arizona

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the facility’s inpatient mental health unit, specific to the subpopulation of patients with a diagnosis of dementia. The OIG team made two visits to the facility in 2017 and 2018. The OIG team found that patients with dementia admitted to the mental health unit had a longer length of stay when one-to-one observation was required. The OIG substantiated that unit staff did not consistently follow the facility’s patient safety observer policy that outlined one-to-one care. The OIG was unable to determine whether a patient was improperly restrained because a seclusion room was not available. At the time of the second visit, both seclusion rooms were available. The OIG was unable to determine whether nurse staffing was adequate to meet patient care needs. Staffing methodology documentation initially provided was not complete; at the time of the second visit, staffing methodology supporting data used to determine nursing hours per patient day after the inpatient mental health unit was separated into two distinct units was also not complete. In 2017, the OIG team substantiated that the inpatient mental health unit was not a therapeutic environment due to the absence of cleanliness and interior updates, patients not wearing personal clothes, and a noncompliant patient advocacy program. In 2018, the OIG team noted a satisfactory improvement in cleanliness after contracting with an external cleaning services company. The OIG substantiated that some staff who worked on the inpatient mental health unit did not have required annual training in accordance with the facility’s policy. The OIG made seven recommendations related to documentation issues, the patient safety observer policy, staffing methodology, training of mental health staff, environment of care, and the patient advocacy program.