Healthcare Inspection – Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility

OIG conducted a healthcare inspection to assess the merit of allegations from a complainant about mental health care provided to a patient at a Veterans Integrated Service Network 16 facility, prior to his suicide. We substantiated that the patient had been reasonably stable on his medication regimen, including clonazepam, for many years and that the patient was not placed back on his preferred medication (clonazepam) by psychiatrists despite his requests to do so. We substantiated that the patient was not admitted to the psychosocial residential rehabilitation treatment program and identified several barriers to the patient’s admission including misconceptions about admission criteria, delays in tuberculosis testing, poor communication between providers, and delays in contacting the patient. We found that, contrary to Veterans Health Administration (VHA) policy, the patient’s treatment preferences were not considered, nor was the patient informed of his right to appeal treatment decisions made by mental health staff. Furthermore, refusal on the part of the patient’s psychiatrist to treat the patient unless he agreed to not taking clonazepam created a treatment impasse and violated VHA policy. We found that because of limited availability of psychiatry appointments, the patient did not have timely access to mental health care after his discharges from community psychiatric hospitals and as his mental health condition worsened, other care options, such as Non-VA care, were not explored. We found that communication and planning by the patient’s mental health providers was not commensurate with the patient’s needs. In spite of the patient’s deteriorating mental health condition, multiple suicide attempts, and frequent hospitalizations, his underlying bipolar disease was not adequately treated, and ultimately, his poorly controlled mood disorder was the likely underlying cause for the patient’s suicidal thinking. We made 12 recommendations.