Marion VA Medical Center suffers staff shortages says internal documents

After a veteran tried to commit suicide at the Marion VA Medical Center in March, hospital staff reported they saved his life. But internal documents describe errors that led to the incident.

The Chronicle-Tribune obtained documents on May 3 detailing a suicide attempt by a veteran admitted to the Acute Mental Health (psychiatry) Unit. These documents are in the form a PowerPoint presentation created and distributed internally as a comprehensive overview of the incident.

The PowerPoint shows a breakdown in protocol inside the hospital’s mental health unit and suggests staff shortages, a continuing problem at the VA medical facilities nationwide, attributed to the failure.

On March 24 a 51-year old veteran was admitted to the psychiatric unit on an emergency detention order. According to the summary of the event in the documents, the veteran was admitted at 6:32 a.m. with a “diagnosis of anxiety with homicidal ideations.” He was placed on suicide status. The patient’s status was changed to restricted about four hours later, after he denied suicidal and homicidal ideations – imagining killing himself or someone else.

According to a response from the VA, this is an acceptable reason to change a patient’s status.

Patients on suicide status require constant supervision by a VA employee. Being on restricted status means a nursing staff member is to observe the patient every 15 minutes, the VA said.

The next day the patient was placed in the Observation Room at the VA, a multi-purpose room, according to documents. The summary states that while in the room, the veteran asked a nurse for deodorant and if he could shower. While staff got items for him, the veteran, “wrapped a bed sheet around his neck, knotted it and threw the knotted bed sheet over the top of the Observation Room door and then shut the door in an attempt to take his life.”

Nursing staff entered the room and removed the sheet from his neck only to have him try to escape by running out of the room and throwing himself at sally port doors.

When that failed, the patient then ran head first into a glass patio door, then a glass window. He was eventually placed in restraints then removed from them the next morning.

According to the presentation, the only noted injury sustained by the veteran in this episode was “a small abrasion to the left wrist” from fighting the restraints put on him. A CT scan was reportedly ordered after the veteran, who recently had had hip surgery, collided with reinforced doors. Yet the presentation notes “a review of the chart lacks documentation that a CT (CAT Scan) was ordered.” 

“... our acute psychiatry unit medical staff at the Northern Indiana Health Care System was successful in saving a veteran’s life,” the VA stated in a response to questions. “Our highly skilled and trained staff responded immediately and should be credited for their quick response and dedication to duty.”

‘When that happened I said I was done’

After reviewing the documents provided, the C-T sent a series of questions asking for clarifications, definitions and further explanations of the incident and the unit’s policies. The VA responded to a limited number of the questions. For those that were not answered, the VA claimed privacy restrictions.

However, further review of the documents, along with interviews with former employees, including a licensed practical nurse who worked in the psych unit at the time, show an apparent breakdown in protocol attributed to a lack of staffing.

The episode was marred with numerous breaches of approved practices, including possible forging of medical charts and improperly taking the veteran off of suicide status without proper evaluation.

Bonnie Straw worked at the Marion VA as a licensed practical nurse for 15 years, 14 of those in the Acute Mental Health Unit. Straw was still an employee when the suicide attempt occurred. She was working the day the veteran was admitted. On March 30, less than a week later, she quit.

“When that happened I said I was done,” she said. “This is ridiculous.”

Straw said that proper protocol was not followed when the veteran was admitted.

“He did not get seen by a psychiatrist,” she said. “He didn’t get seen by anyone until Monday.”

Straw said there is a lack of psychiatric evaluations on the weekends. The veteran was admitted on a Saturday. The licensed practical nurse said veterans are supposed to be seen seven days a week by a psychiatrist, as per protocol by The Joint Commission, a U.S.-based nonprofit that accredits more than 21,000 health care organizations and programs.

“It is not happening. They have a psychiatrist shortage,” Straw said.

The VA stated in its response to the C-T, “Veterans are seen by a mental health licensed independent practitioner and nursing staff every day.”

During the week, Straw said this protocol is followed. The unit is staffed with two registered nurses (RN), one LPN and two nursing aides. A treatment team is present Monday-Friday and includes a psychiatrist, a social worker, psychologist, dietist and a registered nurse.

It’s the weekend that becomes problematic. Straw said on weekends a psychiatrist and an RN is supposed to see each patient. However, there is not a psychiatrist present every weekend.

Claims of falsified documents

On the weekend that the 51-year-old veteran was admitted, a nurse practitioner saw patients, according to Straw. The former VA employee said the nurse practitioner on duty that weekend documented that she had seen all seven veterans for 15 minutes a piece.

“That was not true,” Straw said. “She did not see [the veteran].”

Internal documents state the “veteran was seen by a provider prior to change in status,” though the same slide notes no documentation of an assessment prior to the veteran’s change in status.

There is also the following statement in the presentation: “false/misleading documentation r/t provider rounds on weekends.”

The VA did not respond to a question asking for clarification of the aforementioned statement.

According to the presentation, a veteran on suicide status must be evaluated by a “Mental Health Provider or the MH Treatment team, prior to any change in status.” Later on, the presentation said the “status changed occured prior to the Veteran being evaluated by a MH (mental health) Provider or the MH Treatment team.”

Straw said false documentation is common on weekends because of a lack of a psychiatrist on staff to properly evaluate patients. She also claims the veteran in question had not stated he was no longer experiencing suicidal or homicidal ideations, despite the contrary being alleged in the internal documents.

Straw added that he was taken off suicidal status to accommodate the lack of proper staffing.

“It’s all covered up …,” Straw said of false documentation. “There’s no morals, there are no ethics.”

Straw said a lack of psychiatrists has been a persistent problem since at least December. The licensed practical nurse said there are currently two psychiatrists working in the unit with another who does a walk-in clinic. At one time, the unit had five, she said.

During the week and two weekends a month when a psychiatrist is present, Straw said protocol is followed correctly, but an incident like the one in late March, in which veterans were not seen, has happened on “numerous occasions.”

VA down 34,000 positions across country

Alice Buckley is a former medical manager for primary care at the Marion VA who most recently worked at the VA in 2017. Buckley said the incident sounded all too familiar.

“They were short, very short on the weekends,” she said of the psych unit.

Both Buckley and Straw stated the VA has had trouble keeping psychiatrists on staff.

The C-T sent a follow up email to the VA on May 25 inquiring about the number of patients in the unit and a breakdown of the staffing levels. To date, there has been no response.

The decision to place and briefly leave the veteran in the Observation Room marked a breach of VA protocol as well.

As the internal presentation states, the Observation Room was not included in a Risk Assessment completed every six months. An anti-ligature sensor on the room’s door, which would have detected an attempted suicide, was never installed. At no point in the presentation is it said the Observation Room required a risk assessment. Straw said an anti-ligature sensor prevents any item from being hung on a door, even a jacket.

However, per “VHA memorandum”, the Observation Room should be monitored for “environmental hazards” such as sheets or pieces of clothing which could be used in a suicide attempt. VA policy also requires “line of sight or one-to-one observation” of the occupant whenever the Observation Room is occupied, according to the presentation.

Furthermore, the internal presentation notes the existence of a “Quiet Room” adjacent to the Observation Room would allow for the Observation Room “to function solely as designed,” meaning one-to-one observation of the occupant at all times. This policy appears to have been broken when staff left the veteran unattended to fetch him deodorant and items for a shower.

The VA has planned to take a number of actions to prevent a similar incident, according to the presentation. These include a Risk Assessment on the Observation Room, anti-ligature sensor installed on the Observation Room door as well as a checklist for “float” staff, who are assigned to provide one-to-one observation. All actions listed are to be completed by the end of the first quarter of the fiscal year of 2019 at the latest, or March 31, according to the presentation.

There were 49,000 staffing positions recently reported unfilled nationwide at VA medical facilities in May 2017, according to then VA Secretary David Shulkin. Reports in the New York Daily News suggest that figure dropped to 34,000 by October of 2017.

Issues with staffing at the Marion VA led to a protest in May outside campus gates led by the American Federation of Government Employees (AFGE) Local 1020 chapter. At the protest, workers explicitly complained about shortages on the psychiatric staff.

Dave Miller, a human resources officer for the Northern Indiana VA, said the systemic staffing shortages experienced nationwide by the VA simply did not exist in Marion.

“I really feel like it’s an exaggeration to say there’s that same level of problem here locally,” Miller told the C-T at the time of the protest.