Seven VA Hospitals Flagged on Veteran Suicide

San Diego, Philadelphia, other facilities falling short on best practices

VA Hospital Pittsburgh
February 4, 2016

Multiple Department of Veterans Affairs medical facilities across the country have been flagged in recent months for insufficiencies in their programs to prevent veteran suicides.

In the last five months, seven VA hospitals have been the subject of reports produced by the agency’s inspector general that highlighted insufficient employee training, patient monitoring, and safety planning in their respective suicide prevention programs.

The inspector general found fault with facilities in Butler, Pennsylvania; Philadelphia, Pennsylvania; Columbus, Ohio; San Diego, California; Honolulu, Hawaii; Anchorage, Alaska; and Manchester, New Hampshire.

The Philadelphia VA hospital was the site of a reported veteran suicide in November. The review of the Corporal Michael J. Crescenz VA Medical Center in Philadelphia was completed about a month before a disabled veteran allegedly jumped to his death from a parking garage after seeking psychiatric treatment.

According to the Jan. 14 inspector general report, the vast majority of new employees at the Philadelphia hospital were not trained in suicide prevention or suicide risk management within the required time frame. Fourteen of 15 employees did not undergo suicide prevention training within a year of being hired, hospital records indicated.

The Philadelphia VA hospital did not complete mandated reports on patients who attempted or committed suicide in the year ending in June 2015, the inspector general found. Electronic health records also indicated that 30 percent of patients at risk for suicide were not given a copy of a safety plan spelling out warning signs, coping strategies, and professional and personal resources for support. These plans were also not given to the patients’ caregivers.

In total, six of the VA medical centers evaluated since September did not meet requirements for training employees in suicide prevention or risk management. Three facilities, like the Philadelphia hospital, also did not properly execute all suicide prevention plans.

Moreover, the inspector general faulted the facilities in Butler, Honolulu, and San Diego for not sufficiently monitoring or assessing patients for suicide risk. The investigation into the VA San Diego Healthcare System was requested by Sen. Dianne Feinstein (D., Calif.) when a patient died of a self-inflicted gunshot wound after receiving care. The probe, dated Jan. 5, found that hospital staff did not complete a suicide risk assessment of the veteran, in addition to other violations of VA clinical practice.

At the VA Pacific Islands Healthcare System in Honolulu, health records indicated that more than a third of outpatients were not evaluated at least four times in the 30 days after being flagged as high risk for suicide, as required by facility policy. Nearly all inpatients reviewed also did not receive the same frequency of evaluations after being discharged, according to the Nov. 10 report.

The assessments exposing these inadequate suicide prevention programs were all completed within the last year. Four of the reports were issued in January 2016 alone, and the others were distributed between September and December 2015.

"These reports highlight the enduring problems VA faces in providing America’s veterans the mental health care they have earned," Rep. Jeff Miller (R., Fla.), chairman of the House Committee on Veterans’ Affairs, told the Washington Free Beacon. "The key to curbing the epidemic of veteran suicides is improving the accessibility and effectiveness of mental health care available to our returning heroes."

The reports come at a time when the government agency is struggling to raise awareness about preventing veteran suicide. VA Secretary Robert McDonald and VA undersecretary for health David Shulkin hosted a national summit on veteran suicide prevention on Tuesday.

Miller said that, though Congress passed and President Obama signed the Clay Hunt Suicide Prevention for American Veterans Act aimed at boosting access to VA suicide prevention and mental health services last year, lawmakers must do more.

"To that end, the House Committee on Veterans Affairs is continuing its focus on VA overmedication issues, and Congress is currently considering legislation to address these problems," Miller said.

The committee is also investigating circumstances surrounding multiple veteran suicides and plans to hold a hearing on the implementation of the Clay Hunt Act, which was named after a decorated Marine who committed suicide after serving in Iraq and Afghanistan.

A representative for veterans group Concerned Veterans for America said that the inspector general’s findings raise questions about the government agency’s efforts to prevent suicide.

"These reports raise questions about how suicide prevention efforts are being integrated across the VA, and they are an important step in making sure every single veteran receives the care he or she needs," John Cooper, press secretary for Concerned Veterans for America, said in a statement. "Veterans should have assurance that they will be able to count on the VA when they seek mental health treatment."

The VA’s network of health systems has been under increased scrutiny since it was revealed in 2014 that some hospitals were using fake waitlists to cover up the long waits veterans faced for care. An independent assessment commissioned by the agency concluded last September that its flawed health system needed a system-wide reworking.