Report shows failures at VA hospital where veteran died by suicide in locked unit

West Palm Beach VA
Photo credit VA
By Abbie Bennett and Elizabeth Howe

Failures at a Veterans Affairs hospital in Florida where a veteran died by suicide earlier this year could have contributed to that patient's death, or risked the safety of others, a new report from a VA watchdog shows. 

Inpatient deaths by suicide at VA medical centers are considered "never events" — so when a veteran died by suicide inside a locked mental health unit at the West Palm Beach, Fla. VA Medical Center, an Inspector General investigation was ordered.

The resulting report, released August 22, found that the patient was appropriately screened for suicide risk, provided medication management, placed on close observation status, and had on-going assessments, interventions, and a discharge plan. 

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But in other areas, the OIG report found deficient conditions, nonoperational equipment, inconsistent policies, unmet standards, and a lack of oversight that all could have contributed to the veteran's death. 

Safety and law enforcement cameras hadn't worked for "at least three years." A 15-minute patient safety rounds policy was unclear and failed to set expectations for staff. The facility failed to meet Veterans Health Administration requirements for staffing an Interdisciplinary Safety Inspection Team. They also lacked the staff needed for the Mental Health Environment of Care Checklist. Leaders lacked awareness, failed to educate themselves on patient safety requirements and failed to provide appropriate oversight, according to the report. 

As a result, patients may have gone as long as 25 minutes without being checked, and "had the cameras been fixed and monitored as required ... it is possible that an employee may have seen the patient ... and possibly been able to intervene," the report said. 

Leaders' alleged lack of knowledge or action on the cameras "represented a deflection of responsibility and failure to perform their duties," the report said. Of senior leadership, the report said their disregard of safety risks "reflected a myopic view of the facility's responsibility to ensure patient safety." 

While the unit was sufficiently staffed the day of the veteran's death, one of the nursing assistants assigned to check on patients was performing other duties during that time, the report said. 

And an effort to fix the safety issues and other failings only began after the veteran's death, the report said. "Facility leaders and managers only started to respond aggressively to long-standing deficient conditions after" the death, according to the report. 

Since the Inspector General investigation, VA spokeswoman Susan Carter told Connecting Vets the West Palm Beach VA "has taken action" on recommendations. 

"We continue to reinforce education to all staff and maintain suicide prevention as a priority," Carter said in a statement to Connecting Vets.  "As part of our ongoing structural improvement plan, we continue to make upgrades to all areas of the hospital to provide the safest environment for our patients, visitors and staff."

For more information on potential warning signs of suicide, click here.
If you or someone you know needs help, contact the Veteran Crisis Line 24/7 at 1-800-273-8255 (select option 1 for a VA staff member). Veterans, service members or their families also can text 838255 or go to
Reach Abbie Bennett: or @AbbieRBennett

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