A patient’s death by suicide at a Department of Veterans Affairs hospital in Florida earlier this year might have been prevented if facility leadership had addressed longstanding issues with security cameras and unsafe facility practices, according to a new inspector general report released Thursday.

“Overall, (investigators) found that facility leaders lacked awareness of patient safety requirements and … appeared to accept inaccurate explanations for non-compliance and unsafe conditions,” the findings state. “Facility leaders and managers only started to respond aggressively to long-standing deficient conditions after a (suicide) occurred.”

That death — which happened in March of this year — took place in a secure wing of the West Palm Beach VA Medical Center specifically designed to monitor mentally unstable or compromised veterans.

The report found that the patient received appropriate medical care and monitoring when he first arrived at the hospital and for the following three days. But when his medical discharge was delayed, the veteran became agitated, retreated to his room and ultimately took his own life.

Staff are required to do rounds every 15 minutes in the secure area of the hospital, but investigators found that the welfare check just before the man’s death did not include anyone entering his room to look for signs of distress. That employee was also assigned other duties during the monitoring work, in violation of center policies.

In addition, security cameras on the floor designed to help monitor patients “had reportedly been nonfunctional for years” because of technology issues. And hospital leadership ignored past warnings that room set ups could make it easier for patients to harm themselves, which the report labeled “a deflection of responsibility and failure to perform their duties.”

VA officials said they have made improvements to the Florida site in the wake of the death. Donna Katen-Bahensky, director of the center, told the inspector general’s office that a new treatment plan for unstable patients was put in place earlier this summer and that new cameras would be installed by the end of this month.

Richard Stone, the executive in charge of the Veterans Health Administration, said a new oversight process to ensure safety concerns aren’t ignored will be in place at the facility next month.

Nearly 30 veterans have taken their own lives on VA medical campuses in the last two years, a figure that has prompted increased scrutiny from lawmakers on staff response and monitoring policies.

VA officials have said on multiple occasions in recent months that the the rate of suicide at the department medical sites is actually lower than in past years. About 20 veterans a day nationwide die by suicide, a figure that has remained steady in recent years.

But the West Palm Beach VA findings suggest more can be done at some sites to help veterans in distress. The report notes that a different patient fled the psychiatric facility in December against staff orders, but leadership appeared not to address problems in the months leading up to the suicide.

“Various facility leaders and managers knew, or should have known, about on-going lapses related to the unit’s physical environment, inspection rounds and staff training,” the report states. “Despite this, responsible leaders and managers did not consistently take steps to educate themselves about and ‘own’ the issues, and aggressively problem-solve on behalf of patient safety.”

The investigation came at the request of House Veterans’ Affairs Committee Chairman Mark Takano, D-Calif.

Next week, VA and Department of Defense officials are scheduled to conduct their biennial suicide prevention conference in Nashville, Tenn., to focus on assistance for veterans and servicemembers facing mental health issues.

Veterans experiencing a mental health emergency can contact the Veteran Crisis Line at 1-800-273-8255 and select option 1 for a VA staffer. Veterans, troops or their family members can also text 838255 or visit VeteransCrisisLine.net for assistance.

Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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