In one report, investigators found the Atlanta facility did not sufficiently address patient care safety, failed to monitor patients and did not have adequate policies for dealing with contraband, visitation and drug tests. In the case of the man who overdosed on drugs from a hospital visitor, the report said the man was searched when he returned to his room and given a drug test. However, it was later determined another patient had provided the urine. Investigators said the facility had not provided staff with a policy for collecting urine, which should include securing the bathroom or direct observation. Investigators also noted the unit had no written policy on patient visitors.
The report, which noted high patient satisfaction rates at the Atlanta facility, recommended the VA establish national policies addressing contraband, visitation, urine testing and escorts for inpatients of mental health units. The VA agreed and plans to implement those policies by Sept. 30.
A separate report linked two additional deaths to the facility and its referral program to outside mental health providers. Investigators noted the Atlanta VA Medical Center had referred more than 4,000 patients since 2010 but did not know the status of those patients.
"There is no case management or follow-up," said one unidentified staff member quoted in the April 17 report.
One patient who died had a long history of mental health issues including suicidal behavior. He was evaluated and prescribed medicine for depression. A follow-up appointment was scheduled for four weeks later, and the patient committed suicide during that time, according to the report.
Miller has drafted legislation would address mental health care within the VA system. It would require the VA to contract with civilian contractors for mental health care while also requiring the VA to keep closer tabs on patients after receiving care.
Veterans interviewed at the Atlanta facility on a recent afternoon defended the level of care being provided.
"I've had good treatment here and good care," said Lester Paulus, a 73-year-old retired Navy veteran from Canton, Ga., who received eye surgery and successful cancer treatment.
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