A report shows VA failures may have led to veteran suicide. Congressman calls for 'stand-down.'

Abbie Bennett
August 23, 2019 - 9:59 am

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The day after a watchdog report showed major failings of a Florida Veterans Affairs hospital may have contributed to the suicide death of a veteran earlier this year, the chairman of the House Veterans Affairs Committee is calling for a VA-wide "stand-down."

Rep. Mark Takano, D-Calif., said VA must take action. After three suicides on VA property within five days in April, Takano said he directed the committee to address "the national crisis of veteran suicide, and made it this committee's top priority," Takano said in a statement Friday. 

Takano said the committee held hearings, passed five suicide prevention bills but "with each suicide, it becomes more clear our country is not doing enough." 

Congress has repeatedly tried to bolster VA's veteran suicide prevention efforts. Funding has increased exponentially. 

"Yet it is clear VA must do more," Takano said. "We need new solutions." 

So, Takano called for "an immediate nationwide stand-down to address this crisis." 

An Inspector General report released Thursday, and first reported by Connecting Vets, showed multiple basic safety failings at the West Palm Beach VA that the report said could have contributed to the veteran's death in a locked mental health unit of the hospital. 

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. 

Over-the-door alarms used to prevent veteran suicide also were never installed, despite a VA-wide recommendation. The report showed just 50 percent of VA facilities have installed them. 

Just a third of all hospital employees responsible for maintaining the safety of patients were assigned required suicide prevention training. 

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. 

“Who is responsible for the failures that occurred? Why were steps not taken after previous incidents identified gaps in policies or procedures?" Takano said. "What will VA do to ensure that veteran suicide does not happen on VA’s watch?"

The stand-down Takano called for is intended to ensure each VA employee "understands how to identify veterans in crisis and get them the help they need. VA must conduct a top-to-bottom review of its hospitals and clinics to ensure that all of its facilities offer a safe environment of care for veterans in crisis.

“We cannot keep delaying action. Americans must know that key policies to keep veterans safe are in place, that VA will enforce them, and trust that senior VA leadership will be held accountable.”

The West Palm Beach VA death was the second of now 10 veteran suicides at VA facilities this year. 

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 veteranscrisisline.net.

Reach Abbie Bennett: abbie@connectingvets.com or @AbbieRBennett

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