VAOIG Inspection of the Veterans Health Care System of the Ozarks Fayetteville, Arkansas

Healthcare Inspection Alleged Denial of Care and Quality of Care Issues Veterans Health Care System of the Ozarks Fayetteville, Arkansas 01/13/10. The purpose of this inspection was to determine the validity of the allegations regarding the quality of mental health care provided to a patient. We could not find evidence in the medical record documentation that the provider sufficiently explored relevant aspects of the patient’s recent suicidal thoughts and or further inquired about the location of the patient’s gun. Primary Care Service did not provide the patient with a mental health consult within the required timeframe and did not facilitate further assessment of the patient’s mental health when he presented to the CBOC for unscheduled visits with mental health issues. Although we identified these patient care issues, given all the facts in this case, including those relating to the care provided to this patient both at VA and at non-VA facilities, we cannot conclude that these deficiencies impacted the patient’s outcome. We recommended that managers: (1) require documented discussion in the patient’s medical record regarding access to lethal weapons for patient’s determined by the evaluating clinician to be at heightened risk for suicide; (2) require newly hired providers are initially monitored through chart review to assure new staff are sufficiently adept with use of CPRS, (3) assure patients seen in the primary care clinic and who have mental health needs receive timely referrals; and assure that clinical staff facilitate further assessment of patient’s mental health care needs for patients who present to primary care for unscheduled visits where mental health issues are central to the visit. Management submitted appropriate implementations. VAOIG