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Emergency Department Evaluation Of A Homeless Veteran - Dallas, Texas

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Case Summary

The patient is in his twenties with a history of panic disorder, depression, posttraumatic stress disorder (PTSD), and drug abuse. Facility MH providers have been treating him since April 2012.

In July 2012, a MH provider at the Fort Worth Outpatient Clinic (FWOPC) saw the

patient during a scheduled appointment with complaints of increased anxiety and panic

attacks. The providers note documented that the patient was upset and tearful due to

financial issues and homelessness. The provider asked the patient if he felt like he

needed hospital admission because of the increased anxiety, but the patient felt outpatient services would be enough.

The patient denied SI. The provider adjusted the patients

psychiatric medications and provided him with information on how to get help after

hours if needed and scheduled a follow-up appointment in 2 weeks.

The next evening, at approximately 5:30 p.m., the patient presented to the ED. The triage Registered Nurse (RN) note states that the patient was complaining of increased anxiety,PTSD, and feeling depressed; however, he denied SI.

The note documented that the patient was crying during the evaluation, the provider at FWOPC said admission was possible, and that the patient was recently homeless. The patient reported that the triage RN had him wait in the holding area of the ED.

At approximately 7:30 p.m., the on-call psychiatrist for the ED began evaluating the

patient. The psychiatrists note documented that the patient wanted to be hospitalized for increased anxiety and panic attacks related to finances and homelessness, but the provider did not feel admission was warranted. The patient did not think his current medications(including a new medication started the day before for panic attacks)

were effective; the new medication made the patient drowsy.

The psychiatrist documented that the patient denied depression and SI; however, the patient felt helpless, frustrated, angry, and was worried about the future. The patient had not abused non-prescription drugs for the last 3 weeks but was having cravings that evening.

The assessment documented that the VA Office of Inspector General 3

ED Evaluation of a Homeless Veteran, VA North Texas Health Care System, Dallas, TX

patient was alert and oriented, cooperative, without any psychomotor abnormality, and


The note documented that the psychiatrist spent 30 minutes with the


Through evaluation of the patient, the psychiatrist determined his condition did not

warrant inpatient treatment for stabilization. The psychiatrists plan included the patient

keeping his scheduled follow-up appointment with the FWOPC MH provider and

contacting a social worker to arrange shelter for the patient.

During our interview with the patient, he reported having a panic attack when he was told he would not be admitted.

He stated that the police were called, threatened to arrest

him, and walked him out of the building. He reported that he said, I might as well go

out and kill myself if you are not planning on doing anything for me.

The EHR documented that while the psychiatrist was in the process of contacting a social

worker, the patient left at 10:50 p.m., against medical advice.

Three days later, the patient presented to the FWOPC complaining of anxiety, panic

attacks, and depression about finances and homelessness. The provider noted that the

patient was feeling hopeless, helpless, and felt he needed hospitalization for stabilization

of anxiety and now reported SI. The patient denied having a plan for self-harm but

stated, I just dont care what happens anymore The EHR documented that the

patient relapsed with drug abuse, reportedly to stay calm after leaving the ED.

The FWOPC provider arranged for the patient to be admitted to the facility.

The patient was hospitalized for 8 days and discharged with MH follow-up care at the FWOPC.

He was able to obtain housing in Fort Worth through the Grant Per Diem 6 program.

Inspection Results

Issue 1:

Improper Treatment of a Suicidal Patient

We did not substantiate that a suicidal patient was treated improperly.

Although it was alleged that the patient complained of SI, our review did not support that allegation.

All EHR notes reviewed documented that the patient denied SI but had

feelings of hopelessness and depression.

Although it was alleged that police were called when the patient was having a panic

attack and the patient said he told the police officers he would kill himself, we did not find a police report of this incident. During our interviews, the police officers said that if they are called for an agitated patient, they attempt to calm the patient and would not


Grant Per Diem is a VHA transitional housing program.

VA Office of Inspector General 4 ED Evaluation of a Homeless Veteran, VA North Texas Health Care System, Dallas, TX

write a report if the patient cooperated.

However, all officers emphatically stated that they would never allow anyone to leave who said anything about suicide.

In these cases,

they would document the incident in a report and detain the individual in the ED until medically cleared.

Issue 2:

No Written SOP for ED Patient Evaluation

We found that there is no written SOP for patient evaluation in the ED.

During our interviews, staff reported that all patients are assigned an ED provider after

being evaluated by the triage RN. The ED provider is the patients primary provider in

the ED. If a patient presents with MH concerns, the triage RN is to contact the MH

provider on-call for the ED in addition to assigning an ED provider. Either the ED

provider or the MH provider may evaluate the patient first, but both are to see the patient

and the MH provider is to discuss findings with the ED provider. If admission to the MH unit is deemed necessary, the MH provider is responsible for admission. If the patient is to be discharged home from the ED, the ED provider must see and discharge the patient.

However, there is no written SOP or facility policy describing this process for patient evaluation in the ED.

Issue 3:

Improper Use of EDIS

During our review, we found that the facilitys ED is using EDIS; however, it is not being

used according to VHA guidelines.

We reviewed the patient-tracking sheet from EDIS for the subject patient. The patienttracking sheet did not match the patients EHR. The on-call psychiatrist saw the patient,

but EDIS had no record of the patient being seen. According to the EDIS report, the

patient never left the waiting room. The patient EHR documented that the patient left

against medical advice at 10:50 p.m.; however, EDIS showed that at 11:54 p.m. the

patient was discharged home.

During our interviews, we found that EDIS is not consistently updated in real time by the ED staff as required.

Issue 4:

SW services

During our interviews, we reviewed the process of how SW services are provided to

homeless veterans presenting to the ED after hours. SW services are provided by on-call

social workers from SW Service and not by social workers from MH Service, including

those in the HCHV program.

During our interviews, we found that the HCHV program has provided the ED with a list

of shelters in the Dallas-Fort Worth area that can be offered to patients who wish to go to

a shelter to see if a bed is available after hours. On-call SW Service social workers have

VA Office of Inspector General 5 ED Evaluation of a Homeless Veteran, VA North Texas Health Care System, Dallas, TX

the RN or provider tell the patient to return in the morning or have the patient stay in the

ED waiting room (offering the patient a blanket and a food tray) until morning. They did

not report assisting patients in finding a shelter or referring patients to the HCHV

program from the ED as required by VHA.


We did not substantiate that a suicidal patient was treated improperly in the ED.

We did find that various process issues contributed to the patients experiences in the ED.

First, the psychiatrist involved in the patients care was a MH provider who was working extra shifts in the ED to support continued 24/7 MH services.

The absence of ED orientation for these staff members may have contributed to thepatients long wait time, not receiving the services required, and leaving against medical advice.

The lack of real-time EDIS tracking likely contributed to the EDs failure to recognize the patients true wait time and may not provide the facility with accurate information for process .

Finally, on-call social workers for the ED do not follow guidelines for

providing assistance in helping homeless veterans find a shelter or directing them to the HCHV program the following morning.


Recommendation 1.

We recommended that the Facility Director ensure that the facility

develops a written SOP for emergency department patient flow and orientation is

provided to all emergency department staff and on-call personnel.

Recommendation 2.

We recommended that the Facility Director ensure that EDIS is

used as required.

Recommendation 3.

We recommended that the Facility Director ensure that

SW services are provided in the emergency department as required.


The VISN and Facility Directors concurred with our findings and recommendations and

provided acceptable improvement plans.

(See Appendixes A and B, pages 710, for the

full text of the Directors comments.)

We will follow up on the planned actions until

they are completed.


Assistant Inspector General for

Healthcare Inspections

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