Review of Quality of Care for Patients Seeking Acute Mental Health Care at the Lexington VA Healthcare System in Kentucky

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Lexington VA Healthcare System (system) in Kentucky to determine the validity of an allegation that patients seeking or receiving acute mental health treatment did not receive the care needed.

The OIG substantiated quality of care deficiencies for two patients seeking acute mental health treatment at the system. Multiple staff did not recognize one patient’s personally owned insulin pump as a potential lethal means, which allowed the patient to attempt suicide. Following the attempted suicide, leaders did not implement system-wide actions to mitigate the risk associated with insulin pumps for patients who have suicidal ideation. Additionally, a psychiatrist did not provide a second patient with emergency department discharge instructions or document care in the electronic health record (EHR) consistent with Veterans Health Administration (VHA) policy. The psychiatrist’s documentation included copied and pasted information and a derogatory, critical comment about the patient. 

The OIG determined the System Director and Chief of Staff did not ensure that quality management processes, including safety assessment scoring, a root cause analysis, and peer review, were conducted accurately and completely to address system vulnerabilities and patient safety risks for two patients.

The System Director concurred with and provided action plans for the OIG’s eight recommendations related to personally owned insulin pumps, an insulin pump policy, compliance with discharge instructions, review of a psychiatrist’s EHR entries, accuracy of safety assessment code scores, education on root cause analysis processes, and psychiatrist peer representation at the system Peer Review Committee for psychiatry case reviews. The OIG also published a separate report with one recommendation to the Under Secretary for Health to consider specific VHA guidance related to personally owned insulin pumps as a lethal means when patients are deemed at risk for suicide.