#Middlebury #Veterans #Suicide
VETERANS POST
By Freddy Groves
A veteran with a documented history of suicidal thoughts and attempts, as well as drug abuse and PTSD, committed suicide while left unattended in a VA facility emergency room. The Department of Veterans Affairs Office of Inspector General investigated, and they unearthed the facts … which are not pretty.
They are:
The veteran showed up at the VA facility ER with bladder complaints and depression. He’d been there before, and it was noted in his file that he’d had admissions for substance abuse and suicidal thoughts.
The first medical person (“Nurse 1”) did a triage, which is asking questions to decide how to classify the patient. Instead of using the computer to ask him specific questions (per policy) and record his answers, she did it from memory.
Nurse 1 allegedly told the physician (who was resting in another room) there was a patient waiting. Another person, Nurse 2, did a bladder scan.
An hour later, no physician had shown up. An additional hour later, Nurse 1 left for the day and handed off the records to incoming staff. Later a technician found the veteran on the floor of the room, dead by suicide, still unseen by a doctor.
The OIG investigation revealed:
During the investigation, Nurse 1 could not recall from memory the risk assessment questions she supposedly asked the veteran. Nurse 1 also did not actually alert the physician that patients were waiting. The physician did not respond to an alert from Nurse 2 either about patients waiting and did not get up until the boss came on shift.
The “Door to Doc” policy was severely violated. That performance policy states that the target is 25 minutes from the time a patient walks in the door to the time he’s seen by a doctor – not the two hours and 20 minutes this veteran languished by himself.
Information surfaced that showed facility admin sought to interfere with the OIG investigation, instructing in emails that “appropriate responses to direct questions are: yes, no, I don’t know, and I don’t remember.”
To read the whole report, see www.va.gov/oig/pubs/VAOIG-22-01540-146.pdf.
© 2023 King Features Synd., Inc.
