Inspection report puts VA's future in question

TACOMA - Inspectors issued the Puget Sound Veterans Affairs Health Care System a "preliminary denial of accreditation" because administrators failed to make mental health units safer after a suicide at the Seattle VA hospital.

An inspection report made public Friday shows that after the patient hanged himself from a shower grab bar last fall, the VA identified several items at the hospital that could be used to harm someone but none had been corrected when inspectors visited in May.

The inspection report was the work of the Joint Commission on the Accreditation of Health Care Organizations, a Chicago group that polices the nation's hospitals for the quality of care.

It reviewed operations of the VA hospitals in Tacoma and Seattle and the VA outpatient clinic in Bremerton.

The potential suicide - related problems found, plus VA officials inadequate efforts to identify high-risk psychiatric patients, led the group to issue the preliminary denial of accreditation.

The problems prompted a tour Friday of the Seattle VA hospital by U.S. Sen. Patty Murray, D-Wash., and several VA officials, including Stan Johnson, acting director of the health system.

"I would like to assure veterans we are working on the issues," Johnson said Friday.

All the same, Murray, who sits on the Senate Committee on Veterans Affairs, said she was "very concerned" about the situation, and "will stay on top of it" to make sure the problems are fixed.

The 39-page inspection report cites shower heads and grab bars, shower rods, bed rails and cords on window blinds as among potential problems at the hospital. It also notes other troubles in the local VA system, including problems with medication management and patient assessments.

The VA has until August to fix the problems and be reinspected to regain full accreditation. Repairs will cost about $450,000, money the VA has available, said Dennis M. Lewis, who heads the VA system in Washington, Idaho, Oregon and Alaska.

Lewis said hospital administrators had not been aggressive enough in making changes called for in the inspection report.

"If we've learned anything," it's that "we have to respond quickly to recommendations," said Johnson, who toured the Seattle hospital with Murray.

No administrator has been disciplined in the matter, because the VA sees the failure not as the fault of any one person, but of "several different systems issues" at the hospital, Johnson said.

For instance, safer shower grab bars were on order, one doctor said Friday, but hadn't arrived by the May inspection. The bars are needed in the first place, he said, for disabled veterans in the mental health units.

Johnson also said local VA leadership has been in flux this spring, after the planned retirement in March of director Timothy Williams.

His duties were handled temporarily by the head of the VA medical center in Anchorage, until he returned to that post and turned duties over to Johnson a few weeks ago.

Johnson blames his newness for the reason he told The News Tribune on Tuesday that the VA had no written documentation from the accreditation commission regarding the May inspection. Shown a May 18 letter from the commission about the findings, he apologized Friday, and said he had forgotten about it and the report.

The Tacoma and Seattle hospitals each have two inpatient mental health units. They serve an average of 42 veterans a day.

A patient committed suicide in a mental health unit of the Tacoma hospital two years ago, but that incident did not contribute to the current accreditation troubles, officials said.

There have been no other suicides at the two hospitals' mental health units in 15 years, they said.

The mental health unit Murray spent most time touring Friday in Seattle was where the suicide occurred last fall. She was shown two patient rooms, a nurses' station and a patient area.

Dr. Robert Barnes, associate chief of mental health services, showed the changes that had been made after the May inspection, and pointed out things that still needed to be done.

Cords on blinds had been cut, and pipes under sinks covered up so they couldn't be used in a hanging; guardrails had been removed from beds and metal trash cans replaced with plastic ones.

Barnes said new furniture was on order that patients couldn't throw, and that vinyl baseboards would be removed so they couldn't be ripped out and used as weapons.

He also explained how patients' suicide or violence risk was being more carefully assessed.

"What we've learned here" in the aftermath of the May inspection "has already been passed on" to VA hospitals around the country, said Lewis, the head of the four-state system.

Though Barnes showed where a picture with a sharp-cornered metal frame had been removed from the wall, another hung in the walk-way between the hospital's two mental health units.

Also, a bulletin board visible in the unit listed the last names and privilege levels of patients, even though the May inspection noted a problem with a patient at the Tacoma hospital using a similar board to track fellow patients, for reasons not stated in the report.

After the tour, John Roth, a 24-year-old veteran who served in Iraq with a Stryker brigade at Fort Lewis, said he'd gotten a lot of help in the Seattle mental health unit with his post-traumatic stress disorder after his duty in Iraq.

"God knows, they don't want that to happen," he said, when told of the suicide concerns on the units.

The inspections of the Tacoma, Seattle and Bremerton facilities found other problems in addition to those in the mental health units. That is not unusual when the commission inspects large medical institutions.

The report cited inadequate medication management, incomplete patient assessments and records, clinicians relying on out-of-date physicals before surgery and inadequate follow-up with patients,

It also found nurses providing care without doctors' orders, missing instructions on how patients are to care for themselves, miscommunications between medical providers, handwashing problems and insufficient review of patient outcomes.

Johnson said groups at the hospitals had been assigned to tackle and fix those and other problems as soon as possible.