A Southern Nevada VA Health System facility failed in providing a timely response to an attack and later threat on an employee by a patient last year, according to an inspection report released Tuesday.
The report by the Department of Veterans Affairs Office of Inspector General found the North Las Vegas VA Medical Center neglected to offer the attack victim, a social worker, immediate mental health assistance after the incident, which occurred during a home visit. The facility did not flag the patient’s health records until 45 days later, compromising staff safety, and waited two weeks to notify the worker of a later report of a homicidal threat by the same patient.
The inspection and findings stem from an attack last spring, when a patient scheduled for a home visit swung a socket wrench at the social worker’s head and shouted, calling the worker a liar, according to the health inspection report. The report does not indicate the worker was physically harmed. When the employee got into a work vehicle to flee, the patient swung toward the vehicle window.
About three weeks later, another employee working in the community reported hearing that the patient, who has a history of incarcerations for violence and lives with mental health issues, expressed a desire to kill the social worker.
The patient was not arrested until nearly two months after the initial attack. Police at the time of the arrest were unaware of the reported threat made after the incident. The patient later pled guilty and received a six-month jail sentence.
Though the social worker filed a report with the Las Vegas Metropolitan Police Department the day after the incident, the worker’s supervisor and VA police did not coordinate with the police, resulting in possible delays in the patient’s arrest, the inspection found.
The OIG report criticized the lack of involvement by VA police, calling on them to become “more than passive participants” in the facility’s Disruptive Behavior Reporting System. It also points out that after the attack, a supervisor referred the worker to an employee assistance plan rather than seeking out or coordinating immediate mental health help.
“The OIG concluded that the facility lacks clear and specific policies to guide employees, supervisors, occupational health staff, and Human Resources in their response to emotional and mental health injuries,” the report said.
Investigators also found “frequent vacancies and staff turnover” in the facility’s Housing and Urban Development-Veterans Affairs Supporting Housing program, which affected the ability of staff members to take a coworker on home visits in the event of safety concerns.
The inspection resulted in six recommendations to resolve the report’s findings. A response from William J. Caron, VA Southern Nevada Health System medical center director, states the facility has retrained employees and is working to meet all of the recommendations by the end of the month.