Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, Ohio

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senators Jon Tester and Sherrod Brown to review the care of a patient who fell to his death from a second-story window at the Chillicothe VA Medical Center (Facility), Ohio. At the request of Senator Brown, the OIG also assessed whether the Facility provided grief counseling. The OIG substantiated adequate security and safety measures were not in place and confirmed external windows on the inpatient medicine unit were not secured shut or limited in width of opening as required by Veterans Health Administration policy. The OIG did not substantiate the patient failed to receive an appropriate level of care. The patient had medical and mental health conditions and was managed by both medical and mental health providers on a medical unit. The patient was under special observation status (the patient was to be within the special observer’s eye sight at all times). The special observer was unable to keep the patient under visual observation when the patient entered the bathroom, locked the door, and climbed out the window. The OIG determined that Facility leaders failed to ensure that staff who worked on the unit received required training and competency checks to maintain adherence to Facility policies. The Facility offered grief counseling to the patient’s available family and staff. The OIG found Facility’s attempt to provide an institutional disclosure was inadequate as the Facility did not disclose all significant facts to a family member and did not attempt to locate the patient’s adult child. The OIG made four recommendations related to securing windows in all patient care areas, monitoring compliance with the Special Observation policy and mental health staff training requirements, and conferring with the Office of Chief Counsel concerning family notification of the patient’s death.