Report faults West Palm VA center's procedures, training prior to veteran's suicide

2019-08-23 | The Palm Beach Post

Aug. 22--RIVIERA BEACH - A federal investigation into the March suicide of a U.S. Army veteran has faulted the VA Medical Center in Riviera Beach for a lax and even "myopic" attitude toward some aspects of ensuring patient safety, according to a report released Wednesday.

Sgt. Brieux Dash, 33, died March 14 at the VA Medical Center. Family members told The Palm Beach Post in the days after Dash's death that he had been diagnosed with PTSD.

The report from the Office of Inspector General for the U.S. Department of Veterans Affairs concluded that Dash "received reasonable care" from the hospital's medical staff. But it also found that several security cameras were not functioning properly in the unit where he died and that more than half of the employees working there had not completed required training.

While VA officials had a discharge plan for Dash, "there was no single unifying treatment plan" for him, the report said. The Veterans Health Administration requires such a plan, complete with measurable goals and interventions.

The VA Medical Center also did not have the staffing required on its interdisciplinary safety inspection team, which assesses risks to patients, such as those that corridor doors can create for men and women who want to harm themselves, according to the report.

Only 44 percent of the employees required to have the training were in compliance due to inattention by some of facility's managers, according to the report.

Strategies used to reduce risks to patients in the mental-health unit "could not reliably ensure patient safety," the report said.

Investigators also found that staffing was at the facility was sufficient on the day that Dash died, but noted that a nursing assistant assigned to conduct safety checks on patients performed other duties during that time, contrary to protocols.

While its staff was supposed to conduct 15-minute rounds for most patients, "it was possible to have a span exceeding 25 minutes when a patient was not visually observed by a staff member," the report said.

Also, security cameras in the unit where Dash was housed had been out of operation for at least three years due to inadequate computer-network capabilities.

"Had the cameras been fixed and monitored as required by policy, it is possible that an employee may have seen the patient, who completed suicide in 2019, preparing for the event, and possibly been able to intervene," the report said.

In a statement released Wednesday, VA Medical Center officials said action has been taken to address recommendations from the Office of Inspector General.

"Any time an unexpected death occurs at a VA facility, a comprehensive review is conducted to see if changes in policies and procedures are warranted," the statement said. "Since the time of the review, the West Palm Beach VA Medical Center has taken action on all of the OIG's recommendations."

Shenita Nelson-Simmons, Dash's mother, said she had not seen the report and declined further comment.

Dash's suicide was the second incident within two weeks involving patient safety at the VA Medical Center, which serves thousands of South Florida veterans at its sprawling campus at Military Trail and Blue Heron Boulevard.

His death took place 15 days after a patient opened fire in the medical center's emergency room, injuring two people. Officials from the medical center said the safeguards would be added in response to the incident, although the VA Center has released few details about them.

The suicide also occurred as several VA centers across the nation have had to respond to a patient taking his or her own life. The Washington Post reported in January that 19 suicides occurred on VA campuses from October 2017 to November 2018, seven of them in parking lots.

jwhigham@pbpost.com

@JuliusWhigham