The VA Office of Inspector General (OIG) evaluated allegations about the care of a patient at the Marion VA Health Care System (facility) who died by suicide. The OIG reviewed concerns that the patient’s traumatic brain injury (TBI), pain, and mental health needs were not addressed. The OIG identified additional concerns regarding the management of the patient’s repeated falls, TBI care coordination, suicide prevention efforts, and the absence of an institutional disclosure.
The OIG substantiated that the neurologist did not provide TBI treatment following the patient’s TBI diagnosis and the primary care provider (PCP) did not facilitate recommended follow-up care. Further, facility staff did not ensure timely coordination of community care records highlighting the patient’s TBI treatment needs. The OIG also found the PCP did not coordinate with community providers regarding the patient’s pain management. The OIG did not substantiate that facility staff failed to provide the patient with appropriate mental health treatment.
Facility staff did not address the patient’s multiple reports of falls with strikes to the head. Suicide prevention staff did not notify the patient of high-risk flag activation status, routinely complete safety plan reviews, or accommodate the patient’s communication preferences. Facility leaders also did not consider an institutional disclosure related to the patient’s care due to the lack of identifying any concerns.
Inadequate management of the patient’s TBI and pain care needs, repeated falls, and insufficient suicide prevention efforts may have limited the treatment options available to the patient.
In response to the OIG’s findings and recommendations, the Facility Director shared plans to update procedures on fall prevention, care coordination, and management of high risk for suicide flags. The Facility Director also planned to ensure compliance with community care coordination and scheduling practices.
Marion, IL
United States
