A newly-uncovered report from the Department of Veterans Affairs reveals that suicidal veterans fled the Phoenix VA and likely the emergency department, as well, even though management insisted that losing troubled veterans from the ED had ceased entirely.
In a past report, officially finished June 17, 2015 and made public March 16, the VA admitted that although 10 suicidal veterans had wandered out of the facility, not a single suicidal veteran had eloped from the emergency department since February 15, 2015. The newly-released report added that no suicidal veterans had eloped from the emergency department up to February 9, 2016.
Elopement is defined by the VA National Center for Patient Safety as a patient who knows that he or she cannot leave but does so anyway.
Whistleblowers deep inside the Phoenix medical center knew the assertion about losing zero suicidal vets just wasn’t true. First, it’s likely that suicidal vets left the ED, even though the VA refused to count them as eloping. Second, suicidal vets left other departments in the Phoenix VA. And third, the technical definition of elopement obscured the fact that suicidal vets often left the facility when staff should have assessed them at a higher risk.
Suicidal veterans continued to leave the facility without care throughout 2015, based on data provided by seven Phoenix VA police reports, and it’s likely this trend occurred in the emergency department, too.
The new report, created by the VA on February 9, 2016, in response to follow-up questions regarding the June 17 report, shows the department tried its level best to dodge police findings.
A veteran who was located in the blood pressure check area on March 2, 2015, suddenly grew agitated and said he was going to harm himself with a gun later that day. He then left, and the staff did not place a hold on him. Luckily, police found the veteran unharmed later and brought him back to an urgent care center, where he was assessed and then subsequently released.
In a second case on May 15, 2015, a veteran was listed as suicidal or homicidal, but because the VA did not label him as “at risk,” the facility maintains his sudden departure from VA property did not count as elopement.
While supervised, a veteran in a facility for diminished mental capacity went out for a walk to smoke and suddenly escaped from the premises on May 31, 2015. Police were unable to find the patient after being notified of the incident by VA police. The patient eventually returned to the hospital, a fortunate ending to a volatile situation.
For the other three cases, the VA seems to have scrubbed them of damning implications, though whistleblowers are convinced that once the reports become obtainable, they will show the VA whitewashed those incidents, as well.
Two of the three cases took place in the emergency department. The VA insisted one of the veterans, who came to the emergency room on November 7, 2015, was not “at risk” and so was simply allowed to leave the emergency room.
Another veteran was brought to the emergency department by his family members on September 25, 2015, and once his family had left the facility, the veteran quickly got himself out of the building and into the parking lot, where police then persuaded him to come back into the facility. Staff promptly determined the veteran to be a “low suicide risk.” The VA did not count his leaving to the parking lot a case of elopement. The veteran was discharged later that evening.
The VA also attempted to deny that five suicidal patients had eloped the week of January 23, 2015, by saying it could not find any records, even though by its nature elopement is unlikely to leave any records. Additionally, the VA was provided with an audio recording of a meeting where a social worker testified of suicidal veterans eloping, but department officials conveniently “were not able to access or listen to the audio recording provided, because of compatibility issues between the audio file sent by the whistleblower and our VA devices.”
This reporter was easily able to open the audio file on first try.
After the VA tracked down the social worker, she said that although veterans were definitely eloping from the emergency department, she did not remember any doing so the week of January 23, 2015.
Throughout the rest of the February 2016 report, the VA chose mostly to emphasize what it did right, noting that as of August 24, 2015, the facility increased suicide prevention training time from 15 minutes to 45 minutes during new employee orientation.
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