Safety Concerns When Providing Care in the Community at the VA Southern Nevada Healthcare System in North Las Vegas

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System in North Las Vegas in response to a referral from the U.S. Office of Special Counsel, which contained allegations that facility leaders responded inadequately after a patient attacked and later threatened a social worker. The OIG determined that facility managers failed to timely respond after the social worker reported an assault during a home visit and did not address the social worker’s health needs after the assault. The social worker’s supervisor failed to immediately report the incident to community and VA police. The facility’s policies lacked specific guidance regarding employee emotional and mental health injuries. Further, the OIG substantiated that the social worker was not informed by a supervisor of a homicidal threat, occurring subsequent to the assault, until two weeks after facility leaders became aware of the threat. Deficient communication between the supervisor and the Deputy Chief of VA Police resulted in a delay in notification to the social worker as well as a failure to coordinate with the community police who had jurisdictional oversight. Additional issues included a delay in disruptive behavior flag placement, deficiencies in VA police Disruptive Behavior Committee participation, and vacancies and staff turnover in the facility Housing and Urban Development Veterans Affairs Supporting Housing (HUD VASH) program. The OIG made six recommendations related to staff and supervisor awareness and reporting compliance with patient disruptive behavior incidents occurring outside of VA grounds, traumatic injury needs of staff experiencing a work-related emotional or mental health injury, timely notification of threats to targeted staff, placement of patient record flags, VA police participation in the Disruptive Behavior Committee process, and a review of HUD-VASH staffing and training needs.