VA Health Care

After two patients were found dead on the grounds of a Department of Veterans Affairs (VA) medical center, GAO investigated and found that "high risk" patients--those unable to care for themselves--who wander away are a significant problem at 39 of 158 VA medical centers. In a recent 2-year period, more than 100 searches were conducted for high-risk patients at 20 VA medical centers. Patients leave their treatment settings without staff knowledge primarily when medical center staff (1) underestimate the potential for these patients to wander off without authorization or (2) fail to closely watch all high-risk patients while they are in the facility or on its grounds. During the same 2-year period, about 7,000 searches were conducted throughout the VA system for high-risk patients who were reported missing. About 99 percent of these patients were ultimately found unharmed; 34 were found dead and 19 injured. VA is working to develop search procedures for these high-risk patients who disappear without staff knowledge and approval. The goal is to find these persons before they leave the medical center grounds. But VA also needs to do a better job of monitoring high-risk patients to prevent unauthorized departures in the first place. Further, VA can do more to locate unaccounted-for patients.

GAO found that: (1) high-risk patients leaving VA treatment facilities without staff authorization is a significant problem at some VA medical centers; (2) VA medical centers are not taking sufficient steps to preclude high-risk patients from leaving their treatment facilities; (3) physicians and nurses at these centers are not consistently assessing a patient's potential for leaving without authorization; (4) although VA medical centers are implementing several methods to monitor the whereabouts of their high-risk patients, their monitoring activities are limited; (5) patient monitoring is hampered by the lack of medical center staff and medical center policies that grant patients special privileges; (6) 5 VA medical centers conducted 966 searches for psychiatric and other high-risk patients that left their treatment facilities without permission from October 1990 through September 1992; (7) 957 of these patients were unharmed, 3 were dead, and 5 were unaccounted for; (8) most of the patients that VA classifies as high risk are psychiatric cases, and the majority of these individuals voluntarily admit themselves to VA facilities; and (9) VA has implemented a new search directive that requires each medical center to have a detailed plan that meets minimum criteria for the identification, search, and location of patients who leave treatment facilities without permission.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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