A trio of federal watchdog reports found conditions at Department of Veterans Affairs hospitals that posed risks to mental health patients. Referred to as “suicide hazards” in the reports, investigators identified issues ranging from loose wires to sharp edges, as well as malfunctioning equipment and insufficient training, which they said put mental health patients at greater risk.
In late December, the department’s Inspector General published the findings of three separate investigations on the state of medical facilities in West Virginia, New York and Massachusetts.
At the VA Boston Healthcare System in Brockton, Massachusetts, the Inspector General reported that some defects in the building represent “a critical vulnerability in the facility’s suicide prevention infrastructure,” and merited immediate, national attention, the investigators wrote.
For instance, investigators reported that the Brockton hospital had exposed plumbing and unsecured equipment or cords that could be used for hanging or strangulation, as well as sink faucets and handles lacking tapered or rounded designs, and cabinet door handles with protrusions that patients could use to self-inflict injuries.
“Given the seriousness of the issue and similar concerns identified at other facilities, the [Office of the Inspector General] is broadly disseminating these preliminary findings to ensure that other Veterans Health Administration (VHA) facilities are aware of this vulnerability and can proactively address similar suicide risks across the enterprise,” reads the report.
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In response to the findings, the Brockton staff removed some of the “hazardous” items and implemented 15-minute patient safety checks, training on specific environmental hazards, and continuous observation periods. Hospital leadership also did their own risk assessment and developed “long-term corrective actions,” but the report did not specify what those were.
The Inspector General reported similar suicide risks at hospitals in New York in two other investigations.
At the Margaret Cochran Corbin VA Campus in New York, investigators found a nonfunctional panic button for patients and staff to use to call for help. The Inspector General also found fire doors with three-point hinges that posed “ligature risks” — objects or structures that patients can use to attach materials like a rope or bedsheet to hang or strangle themselves.
At the Martinsburg VA Medical Center in West Virginia, investigators observed “unapproved” window covers in patient bedrooms that also had ligature risks and had been previously scheduled to be replaced. There was also “potentially unsafe equipment” in a shower room, which the report’s authors said could be used to prevent staff from reaching patients faster in emergencies.
Training gaps on environmental hazards
Beyond calling for improvements to the physical safety at VA hospitals, reports on VA hospitals in West Virginia and New York found that staff did not meet their annual requirements for environmental hazard training, which the reports’ authors said were used to “reduce risks for veterans and staff in the inpatient unit.”
The annual training focuses on the risks posed by things like broken furniture or loose wires.
At both the West Virginia and New York hospital systems, the Inspector General found that nearly three-quarters of the relevant staff did not complete their necessary environmental hazard training.
In response to the reports’ recommendations, hospital directors for the two state VA facilities told the investigators that they would document required training for staff and monitor compliance from the facilities’ safety inspection teams to reduce safety hazards.
If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States. Reach the National Suicide Prevention Lifeline by calling or texting 988 and you’ll be connected to trained counselors.
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Patty is a senior reporter for Task & Purpose. She’s reported on the military for five years, embedding with the National Guard during a hurricane and covering Guantanamo Bay legal proceedings for an alleged al Qaeda commander.