VA acknowledges hospital had suicide risks

SEATTLE – Department of Veterans Affairs hospital administrators in Seattle acknowledged Friday that they were slow to remove shower heads, handrails and other fixtures that could pose risks to psychiatric patients following a suicide last fall.

But they told Sen. Patty Murray during a tour of the Seattle hospital that the delay came partly because they were trying to balance the suicide risks with concern for patients who need fixtures such as shower or bedside handrails – soldiers who have been wounded in Iraq or aging Vietnam veterans, for example.

In reviewing a death at the hospital last November, in which a patient was found hanging from a support rail, a staff team early this year recommended removing the bars from rooms in the psych wards.

But in May, when inspectors from a nonprofit hospital standards group, the Chicago-based Joint Commission, arrived, the rails were still in place. Picture frames with sharp metal corners hung on the walls, and fire extinguishers sat behind breakable glass panes. The furniture in the common areas was neither terribly heavy nor bolted down – in other words, throwable.

The commission inspectors cited problems that included nurses failing to wash their hands, poor treatment records, and outdated medication, but the preliminary decision to deny accreditation to the VA’s hospitals in Seattle and Tacoma was based on conditions in the psych wards.

“What happened in those four months?” Murray, D-Wash., asked her tour guides. “Can I be absolutely blunt? I heard it wasn’t a resources issue. … It was a lack of leadership issue.”

Dennis Lewis, director of the VA Northwest Health Network, and Stan Johnson, who moved to Seattle two weeks ago to become the hospital’s director, acknowledged that administrators dropped the ball in responding to the staff’s recommendations following the suicide. They said the VA is responding to all of the Joint Commission’s findings.

“If the staff here learned anything, and us as directors have learned anything, it’s you have to respond quickly to the suggestions and recommendations made by your staff,” Johnson said. “When they’ve identified an issue, we have to resolve it as soon as possible.”

The VA has removed rails from the beds and ordered 70 new beds and extra-heavy furniture for the psych wards at the Puget Sound hospitals. It has also removed pictures from the walls, except in public areas, and is taking other steps such as covering pipes under bathroom sinks with metal cylinders to prevent patients from hanging themselves on them.

The effort is costing $450,000, and administrators said they expected their experience to prompt other VA hospitals around the country to reevaluate their psychiatric facilities. Health care for veterans has been a top concern in recent months following accounts of shoddy treatment at the Defense Department’s Walter Reed Army Medical Center.

The Joint Commission, which sends inspectors for unannounced visits every three years, had never before complained about the support rails, picture frames or other items it cited in a preliminary report last month, administrators said.

“This ward is unchanged since they were here three years ago,” Robert Barnes, associate director for mental health services at VA-Puget Sound, told the senator.

The report said VA officials knew in February that suicidal patients could use several room fixtures to hang themselves, but “rejected that these were viable risks and elected not to correct.”

The VA initially refused to release the document, but Murray, a senior member of the Senate Veterans Affairs Committee, released it Friday after obtaining a copy. It is particularly disconcerting given reports that as many as 40 percent of troops returning from Iraq have mental health issues, Murray said.

The troops are “coming home with much higher stress levels than we have seen,” she said. “We know we need to get our VA facilities to a different place than they were even a decade ago.”

She spent nearly two hours touring the hospital’s two psychiatric wards. She repeatedly asked VA officials to let her know if they need more money.

On Thursday, officials said the Army is planning to hire at least 25 percent more psychiatrists, psychologists and social workers to help a growing number of soldiers with post-traumatic stress disorder and other mental health needs.