Review of Inpatient Mental Health Unit Processes at the West Palm Beach VA Healthcare System in Florida

The VA Office of Inspector General (OIG) initiated a healthcare inspection following inquiries from several members of Congress regarding the death of a patient (patient 1) perpetrated by another patient (patient 2) on the inpatient mental health unit at the West Palm Beach VA Healthcare System (facility). One of the inquiries was related to whether facility leaders sustained corrective measures recommended after a 2019 OIG inspection prompted by a patient’s suicide on the same unit. 

The OIG found that inpatient mental health unit staff did not follow Veterans Health Administration (VHA) Mental Health Environment of Care (EOC) Checklist requirements associated with patients using wheelchairs, specifically regarding patient 1’s room assignment and assigned patient safety observation level. During the inspection, facility leaders revised the room assignment screening process to align with VHA requirements.

The OIG identified findings similar to the 2019 OIG inspection, including inconsistent patient safety observation practices and inaccurate documentation, inappropriate assignment of additional staff duties, and facility policy that did not align with VHA requirements. Although leaders became aware that staff were not performing patient safety observations correctly and identified strategies for improvement, changes were not implemented.

As a result of the inspection, facility leaders updated facility policy to require provider orders before discontinuing a patient safety observation level and adding a direct line of sight observation level. Updated policy prohibits staff from performing patient safety observations while completing other duties. The OIG issued six recommendations to the Facility Director addressing mental health environment of care checklist requirements, observation practices, training, oversight processes, and documentation discrepancies.

The Veterans Integrated Network and Facility Directors concurred with the recommendations. The Facility Director provided action plans that included staff education on the mental health EOC checklist and patient safety observation requirements, and auditing patient safety observation practices to ensure staff compliance.