Report No. 09-02987-60 January 13, 2010

VA Office of Inspector General 

Washington, DC 20420 

 

Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Alleged Denial of Care and Quality of 

Care Issues 

Veterans Health Care System of the 

Ozarks Fayetteville, Arkansas 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Executive Summary 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted 

an inspection to determine the validity of allegations regarding the quality of mental 

health care received by a patient at the Gene Taylor Community Based Outpatient Clinic 

(Mt. Vernon CBOC), in Mount Vernon, Missouri. 

The Honorable Jo Ann Emerson, Representative from the 8th Congressional District of 

Missouri, requested the VA OIG review allegations that a constituent was denied care at 

the Mt. Vernon CBOC. Specifically, the complainant alleged the Mt. Vernon CBOC 

denied a patient’s repeated requests for hospitalization when he presented to the CBOC 

with complaints of anxiety, depression, a belief his current medications were not 

working, and a recent history of handling his handgun in a way that concerned his 

spouse. In addition, the complainant alleged inadequate monitoring of the patient’s 

mental health condition. He died of a self-inflicted gunshot wound the following day. 

Although the patient was not hospitalized, we determined that bed availability at the 

Fayetteville VAMC was not the driver for the provider’s decision to not admit the patient 

to a mental health unit. However, we could not find evidence in the medical record 

documentation that the provider sufficiently explored relevant aspects of the patient’s 

recent suicidal thoughts and or further inquired about the location of the patient’s gun. 

Finally, the CBOC primary care service did not provide the patient with a mental health 

consult within the required timeframe and did not facilitate further assessment of the 

patient’s mental health when he presented to the CBOC for unscheduled visits with 

mental health issues. Although we identified these patient care issues, given all the facts 

in this case, including those relating to the care provided to this patient both at VA and at 

non-VA facilities, we cannot conclude that these deficiencies impacted the patient’s 

outcome. 

We recommended that the VISN Director ensures that the Medical Center Director: 1) 

requires documented discussion in the patient’s medical record regarding access to lethal 

weapons for patient’s determined by the evaluating clinician to be at heightened risk for 

suicide; 2) requires newly hired providers are initially monitored through chart review to 

assure new staff are sufficiently adept with use of CPRS, 3) assures patients seen in the 

primary care clinic and who have mental health needs receive timely referrals; and 

assures that clinical staff facilitate further assessment of patient’s mental health care 

needs for patients who present to primary care for unscheduled visits where mental 

health issues are central to the visit. 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable corrective actions. (See Appendixes A and B, pages 19–21, for 

the full text of the Directors’ comments.) We will follow up on the planned actions until 

they are complete. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, South Central VA Health Care System (10N16) 

SUBJECT: Healthcare Inspection – Alleged Denial of Care and Quality of Care 

Issues, Veterans Health Care System of the Ozarks, Fayetteville, 

Arkansas (2009-02987-HI-0166) 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted 

an inspection to determine the validity of allegations regarding the quality of mental 

health care received by a patient at the Gene Taylor Community Based Outpatient Clinic 

(Mt. Vernon CBOC), in Mount Vernon, Missouri. 

Background 

The Honorable Jo Ann Emerson, Representative from the 8th Congressional District of 

Missouri, requested the VA OIG review allegations that a constituent was denied care at 

the Mt. Vernon CBOC. Specifically, the complainant alleged the Mt. Vernon CBOC 

denied a patient’s repeated requests for hospitalization when he presented to the CBOC 

with a suitcase and complaints of anxiety, depression, a belief his current medications 

were not working, and a recent history of handling his handgun in a way that concerned 

his spouse. In addition, the complainant alleged inadequate monitoring of the patient’s 

mental health condition. He died of a self-inflicted gunshot wound the following day. 

The Mt. Vernon CBOC is one of four CBOCs associated with the Veterans Health Care 

System of the Ozarks, Fayetteville, Arkansas (Fayetteville VAMC). The Fayetteville 

VAMC is part of the South Central VA Health Care Network – Veterans Integrated 

Service Network (VISN) 16. It is categorized as a very large CBOC and it serves over 

15,000 unique patients. Provided services include primary care and outpatient mental 

health, referred to as the Behavioral Health Service (BHS). 

At the CBOC, 13 teams comprised of a physician, a registered nurse (RN), and a clerk, 

provide primary care services. New patients are randomly assigned to a primary care 

team. Because offering some mental health treatment in the primary care setting may 

reduce stigma and may facilitate acceptance and transition of care if needed to the mental 

VA Office of Inspector General 1 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 2 

health clinic setting, local policy at the CBOC allows primary care physicians to treat 

mental health diagnoses with up to two trials of antidepressants if they feel comfortable 

doing so. They may also refer patients with mental health needs to an Advanced Practice 

Nurse (APN) for consultation and primary care. APNs at the CBOC are Mental Health 

Clinical Nurse Specialists who may prescribe a variety of medications including those to 

treat depression and anxiety. The APN sees the patient for one to four visits to determine 

if the patient should remain under treatment with primary care or if they would benefit by 

further assessment and treatment by the BHS. CBOC primary care physicians and APNs 

are privileged to refer patients for inpatient mental health admission if needed. Finally, 

patients may self refer and primary care physicians may refer patients immediately to the 

BHS. The services BHS provides include general mental health, substance abuse, post 

traumatic stress disorder (PTSD), suicide prevention, and mental health intensive case 

management (MHICM).1

 

The Fayetteville VAMC is a 72 bed facility that provides acute medical, surgical and 

psychiatric care. Located approximately 100 miles from the CBOC, it has a 15 bed 

psychiatric unit and is the CBOC’s main referral hospital. If a practitioner determines a 

patient requires medical or psychiatric inpatient admission, the patient is transported to 

the Fayetteville VAMC, another VAMC, or is admitted to a local community hospital. 

Patient acuity and bed availability determine the final disposition of patients who 

practitioners determine require admission. 

Scope and Methodology 

We interviewed the complainant in person. We interviewed the Butler county coroner by 

telephone. In addition, with permission of the complainant, we obtained and reviewed 

the coroner’s report and related laboratory test results. We conducted site visits at the 

Mt. Vernon CBOC August 18–20, 2009 and at the Fayetteville VAMC on September 1, 

2009. We interviewed medical center management, psychiatrists, RNs, APNs, 

pharmacists, the Suicide Prevention Coordinator, and administrative clerks. We 

reviewed policies, procedures, directives, and the patient’s medical records. We also 

reviewed practitioner personnel files, credentialing and privileging folders, peer reviews, 

and background checks. We reviewed the patient’s VA electronic medical record and, 

with the complainant’s permission, we reviewed records from an outside community 

hospital at which the patient had previously been treated. In addition, the complainant 

provided us with copies of the police report related to the patient’s death, and with copies 

of an evaluation and notes by a private therapist who had briefly seen the patient earlier 

in the year. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

 

1

 An intensive case management program for patients with severe mental illness. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 3 

Case Summary 

The patient was an Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 

Veteran who, between 2004 and 2006, served two, 1-year tours in Iraq with a 4-month 

break between the two tours. A 30-year military Veteran who retired from the National 

Guard in 2008, he was in his mid-fifties, lived with his wife, and had no documented 

service related disabilities. 

Summary of Events Prior to Receiving Care at the Mt. Vernon CBOC 

Prior to receiving care at the Mt. Vernon CBOC, the patient received medical and mental 

health care between March and September 2007, at the Marion Illinois VA Medical 

Center (VAMC) and at the Paducah CBOC, one of seven CBOCs associated with that 

VAMC. Because he was an Iraq war Veteran, the Marion VAMC conducted screening 

for PTSD, depression, and alcohol abuse;2

 the PTSD screen was positive. He received 

mental health evaluations from a social worker, an APN, a psychiatrist, and a therapist. 

He was diagnosed with anxiety, depressed mood, and possible PTSD during this time. 

He was prescribed an antidepressant that is also used for anxiety. In October 2007, he 

cancelled a follow-up mental health appointment scheduled at the Paducah CBOC. He 

did not reschedule the appointment. He had no further mental health related 

appointments at any VA facility until April 2009. In July 2008, he had coronary artery 

bypass surgery at a non-VA hospital. 

In October 2008, the patient received a flu immunization at a CBOC in Branson, 

Missouri, one of the four CBOCs associated with the Fayetteville VAMC and located 

approximately 70 miles from Mt. Vernon. Two weeks later, he presented to the Branson 

CBOC without an appointment and requested a prescription refill for stomach upset. 

Around that time, he and his wife were moving and he was transferring his care to the 

Mt. Vernon CBOC, where a new patient evaluation appointment was scheduled for early 

November. Because it is VHA policy to accommodate Veteran needs during times of 

travel, 3

 a Branson CBOC physician reordered the prescription as requested. After 

receiving the stomach upset prescription refill, the patient cancelled the Mt. Vernon 

appointment and one that was subsequently rescheduled for mid-November. 

In late October and early November 2008, the patient was seen by a private, non-VA 

therapist for uneasiness, mild depression, and life changes. He reported feeling 

somewhat lost, not knowing what to do with himself since his retirement from a military 

career. He reported anxiety related to estranged family relationships. He also reported 

becoming frequently agitated for no apparent reason and marital problems. He denied 

 

2

 VHA Directive 2005-005, Implementation of the National Clinical Reminder for Afghan and Iraq PostDeployment Screening, December 1, 2005. 

3 VHA Directive 2007-016, Coordinated Care Policy for Traveling Veterans, May 9, 2007. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 4 

suicidal or homicidal ideation,4 but reported spending a lot of time thinking about his 

time in Iraq, ruminating on friends he had lost in his unit. He told the private therapist 

that re-adjustment had been very hard. He denied prior ongoing mental health treatment, 

but reported that he was seeing a counselor at the Mt. Vernon CBOC in addition to his 

primary care physician. He received a provisional diagnosis of major depression - mild, 

and generalized anxiety disorder. The therapist noted that PTSD could not be ruled out 

and further assessment was needed. It was the therapist’s assessment that the patient 

might need medication as well as cognitive behavioral therapy. The therapist encouraged 

the patient to see a physician to determine the need for an antidepressant. 

The patient was seen again by the private therapist in late November 2008. During this 

appointment, he recalled having had panic attacks at some point in the remote past that 

was treated with the anti-anxiety medication chlordiazepoxide (Librium). He said he was 

currently experiencing anxiety, but believed he could control it himself. He told the 

therapist he would go to the VA clinic in Mt. Vernon to address medication issues. 

Summary of Events After Beginning Care at the Mt. Vernon CBOC 

The patient’s next encounter with a VA healthcare facility occurred at the Mt. Vernon 

CBOC in early April 2009, where he received a comprehensive, new patient evaluation. 

He did not see his assigned primary care physician because she was on leave. He was 

evaluated instead by a recently hired physician who had worked at the CBOC for 

approximately 1 month. He received required screening for PTSD, depression, and 

alcohol abuse; the PTSD and depression screens were positive. He told the physician he 

did not believe his current antidepressant was effective and he was feeling depressed. He 

denied thoughts of suicide. The physician’s impression included a diagnosis of 

depression and she changed his antidepressant to one he had experienced success with in 

the past. She documented the positive PTSD and depression screening results and noted 

he should receive a mental health consult within 14 days; however, she did not properly 

order the consult through the Computerized Patient Record System (CPRS). 5

 

Three days after the Mt. Vernon CBOC evaluation, the patient left the couple’s home and 

went to a local motel. He was gone for 5 days before he called his wife. He asked her to 

come get him because he said he could not drive. When his wife arrived he became 

angry, told her to call the police, and drove away in his truck. She called 911 on her cell 

phone and the police pulled the truck over. The police reportedly found a gun and 

ammunition in a plastic bag in the truck and the patient was transported by ambulance to 

a community hospital emergency department for evaluation. 

 

4

 Thoughts of killing self or others. 

5

 An electronic medical record application used to enter orders and manage all information connected to any patient 

in the VA healthcare system. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 5 

Emergency department documentation related to this event does not make reference to 

the patient having left the couple’s home for 5 days, the interaction with the police, or the 

presence of the gun/ammunition in his truck. Documentation did include that the patient 

reported depression, “doing things that I don’t understand,” increasing irritability, and 

arguing with his wife. He reportedly stated that he wanted to make it work, but was 

feeling like he did not feel in control of the situation. The notes indicated that the current 

episode had started more than a week earlier and had gotten progressively worse. Over 

the prior month, the patient reported that he had gradually become increasingly 

argumentative and was easily agitated. He endorsed depression and memory loss. He 

denied suicidal ideas, insomnia, and psychotic symptoms. His speech and behavior were 

described as normal and his affect as blunt.6

 He told the clinician that, although he had 

been prescribed anti-depressant medication, he had not been taking an anti-depressant for 

1.5 months. (He reportedly told his wife that he had forgotten.) 

The emergency department evaluation also included blood analysis and an 

electrocardiogram (EKG), which were largely unremarkable. The emergency department 

physician noted his thyroid stimulating hormone level7

 was slightly above the reference 

range, so he was advised to follow this up with his primary care doctor. He was also 

advised to take his anti-depressant medication. The hospital’s mental health unit screener 

also evaluated the patient while he was in the emergency department. The patient 

reportedly stated he was feeling better and he was discharged from the emergency 

department to his home with instructions to follow up at the VA. 

Three days after the emergency department evaluation, the patient sought unscheduled 

care at the Mt. Vernon CBOC where he requested an EKG, which was performed and 

determined to be normal. During this encounter, he told the triage8

 nurse he had a “panic 

attack” and was taken to an emergency room by ambulance. Documentation does not 

reference or indicate mention of the events that led to the non-VA hospital emergency 

department visit 3 days earlier. The patient told the triage nurse that he had not filled or 

started taking the new antidepressant prescribed by the Mt. Vernon physician in early 

April. He denied suicidal ideation. He was discharged to home with the advice to get the 

antidepressant prescription filled and to call if he continued to have problems. 

The following week, the patient’s assigned primary care physician noted a possible 

concern related to cholesterol and hypertension medications. The patient was receiving 

medications for these conditions from the VA and the physician was concerned that he 

was also taking similar medications prescribed by a private physician. The matter was 

resolved that day when the clerk called the patient, who reported he would finish the nonVA prescribed medications before starting the VA prescribed medications. At the end of 

April and again towards the end of May, CBOC staff also called to remind him to 

 

6

 A severe reduction in emotional expressiveness. 

7

 A blood test to detect problems affecting the thyroid gland. 8

 A nurse assigned to assess patients who present to the clinic, without a scheduled appointment, requesting care. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 6 

complete and mail a colorectal screening card. There is no indication that mental health 

concerns were raised during these telephone contacts. 

At the end of May, the patient again sought unscheduled care at the Mt. Vernon CBOC. 

He told the triage nurse he had been experiencing more anxiety and had increased his 

new antidepressant medication without consulting a physician. He also told her he was 

“good at this time.” The triage nurse contacted his assigned primary care physician who 

increased his prescribed anti-depressant to the dosage the patient was then taking and 

directed the triage nurse to advise the patient to not increase the dosage again on his own. 

The patient was instructed to call with any problems. The physician also wrote, “Does he 

need to see MHC?”9

 There is no documentation this question was presented to the 

patient during this interaction. 

Three days after requesting the antidepressant dosage increase, the patient called the Mt. 

Vernon CBOC and requested to see someone in the mental health clinic. He said he was 

“reverting back to his old ways” and he wanted to have someone to talk to about his 

problems. His assigned primary care physician ordered a mental health consult that day 

and the following day a BHS psychiatrist telephoned the patient to perform an initial 

assessment. The purpose of this call was to assess the patient’s safety and to determine if 

his needs were urgent or routine. During this assessment, the patient told the psychiatrist 

he needed help with his mood and depression. He said his current medications were no 

longer effective. She noted he did have access to a gun, but that he denied any suicidal or 

homicidal ideation. Based on this telephone assessment, the psychiatrist determined the 

patient’s mental health needs were not urgent. She scheduled a comprehensive mental 

health consult to be performed in 3 business days. 

A mental health APN assigned to the primary care clinic performed the scheduled mental 

health consult. The patient was neatly dressed, he made good eye contact, and he was 

personable. He said he had had a coronary bypass and was advised he might experience 

problems with anger. He acknowledged he was angered easily, and that he was 

experiencing marital and family problems. He said he had experienced anxiety problems 

10 years before due to a marital crisis. He told her he had received mental health care at 

the Paducah CBOC and that he had also seen a non-VA mental health clinician earlier in 

the year, but he could not recall the provider’s name or the visit dates. He denied other 

psychosocial stressors or serious health problems. He told her he had a gun in the home, 

but denied suicidal or homicidal ideation. Finally, he reported good social support, 

feelings of economic security, and the ability to enjoy everyday experiences. The APN 

completed a suicide risk assessment and noted the patient did not appear to be a danger to 

himself or others. She noted that he denied feeling hopeless, of having thoughts of taking 

his life, of any prior history of suicide attempts, or of a family history of suicide attempts 

or mental illness. Her impression during this visit was that the patient was depressed. 

 

9

 Mental Health Clinic. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

She continued his prescribed antidepressant, and added a prescription for an anti-anxiety 

medication - buspirone (Buspar). She also scheduled appointments for him to see a BHS 

psychologist in 2 weeks and to follow up with her in 6 weeks. 

Summary of Events the Day Before and the Day of the Patient’s Suicide 

Nine days later, the patient phoned the Mt. Vernon CBOC and asked to speak with the 

APN who had performed his initial mental health evaluation. It was after 3 p.m. and he 

was in the CBOC parking lot. The clerk told him to come inside and he would be seen. 

Soon after, the patient and his wife entered the clinic and a triage nurse performed an 

assessment. He told the triage nurse that he was anxious, depressed, and his medications 

were not working. He also told her he had taken his pistol out the night before and his 

wife found him holding the gun. He said he was taking the ammunition clip out and then 

putting it back in. The patient’s wife validated the patient’s account of the prior evening. 

He said he was not sure what he was thinking and he stated he would not hurt his wife. 

The patient shared that he had always been in control, but now he felt out of control. 

When asked where the gun was, the triage nurse asserted the patient’s wife told her she 

had removed the weapon. Because she viewed the account of the night before as a 

possible suicidal gesture, the triage nurse placed the patient on direct observation as a 

precaution until he could receive further evaluation. 

The APN whom the patient had requested was with another patient and was not available 

to see him, but another mental health APN volunteered to see him. That APN came to 

the triage area to meet the patient and to take him to her office for evaluation. The 

patient was accompanied by his wife. The APN recalled the patient as pleasant and calm 

and said his wife was tense and appeared to be holding back tears. The APN reported 

having understood from the triage nurse that the patient was there because he had a pistol 

out the night before. He thought his wife was in bed, but she got up and found him with 

a gun which had subsequently been removed. The APN did not further inquire about the 

current location of the gun with either the patient or his wife during this encounter. 

During the APN evaluation, the patient’s wife told the APN about events surrounding his 

April visit to the emergency department at the non-VA hospital. The APN assessed the 

patient for symptoms of depression and explored whether he had experienced prior or 

recurrent episodes of depression in the past. She then assessed him for anxiety 

symptoms and surmised that he was anxious and possibly had PTSD. The patient told 

her his medications were not working, and he had daily thoughts about Iraq. He 

reportedly indicated that he had been to a counselor, but had stopped going because the 

counselor would break appointments. He reportedly declined to provide the APN with 

the name of the counselor when asked. The APN asked the patient if he had thoughts of 

hurting himself to which he replied “No.” 

VA Office of Inspector General 7 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

At some point during the interview, the patient’s wife got up and left the room. The 

APN closed the door and continued the interview with the patient. The APN asked the 

patient if his wife was alright to which the patient replied “I guess.” Once alone with the 

patient, the APN asked what the patient had been thinking about when holding his gun 

the night before and he replied that he did not know. The APN asked what he was 

thinking when the gun was in his lap. Again the patient replied “I don’t know.” When 

asked what he was doing with the clip, the patient reportedly said he “was putting it in 

and taking it out.” He denied pointing the gun at any part of his body. He said his wife 

was his soul mate, but he did express concern that he “gets angry with her.” He denied 

thoughts of harming her or getting angered with others. 

The patient also told the APN that he had not been truthful about suicidal ideation with 

the APN he had seen for the mental health evaluation 9 days earlier. In addition, he told 

the APN that he had “scammed” the military about PTSD (under-reported symptoms) 

after he returned from Iraq. The patient was described as hesitant to disclose too much. 

The APN told him during this encounter that he needed to be honest with her and from 

that point on she believed their interactions were honest and truthful. 

During this assessment, the APN reportedly asked the patient “What do you want me to 

do for you?” to which the patient replied that he wanted to get back in control of his 

feelings. He said he felt more sad than happy, but that he was sleeping and his appetite 

was good. He denied current thoughts of suicide, but reported that when he did have 

these thoughts he felt worthless, helpless and hopeless. He did not display psychotic 

symptoms. She diagnosed the patient with major depression, recurrent, moderate; panic 

disorder; and rule out PTSD. They then discussed a plan for medication changes and 

reportedly he seemed agreeable with the new plan. 

The APN reviewed medication changes with the patient which included tapering his 

present antidepressant (citalopram); beginning a different antipressant, venlafaxine 

(Effexor); and beginning clonazepam (Klonopin) up to twice a day to manage his anxiety 

and panic. The patient was asked but reportedly denied having previously been treated 

with venlafaxine. She also reviewed the importance of taking the medications as 

ordered, of coming to appointments, and of calling the clinic if problems or concerns 

should arise. She advised him to call the clinic or the suicide hotline if he became 

suicidal. She reminded him that he had an appointment in 5 days with a Mt. Vernon 

CBOC therapist and with her in 1 month to follow up with his medication management 

and to allow time for the medication change to have an effect. 

After reviewing the plan with the patient, the APN went to the waiting area and brought 

his wife back to the office to discuss the plan with her. After returning to the APN’s 

office, the APN reported stating “your husband and I have discussed a plan and want to 

see what you think of it.” The APN reviewed the medication changes with his wife 

present and the wife agreed to keep control of the medications. The APN told them he 

VA Office of Inspector General 8 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

was to return for a follow-up appointment in 4 weeks to allow time for the medication 

change to have an effect. She also reminded them that he was already scheduled to see a 

psychologist at the CBOC in 5 days. The APN documented that she had discussed the 

benefits, alternatives, and rationale of the treatment plan and that the Veteran 

participated in and agreed to the plan. She also noted she did not think he was a danger 

to himself or others at that time. The APN reported that the patient and his wife seemed 

agreeable with the plan to go home. This evaluation lasted 25 minutes. 

As the patient and his wife were checking out with the clerk, the APN maintained that 

she told the patient “if you think this is not a good plan in the morning, I will personally 

arrange a hospital stay.” The clerk also reported hearing the APN tell the patient that if 

he decided the next morning that he would like to be admitted, he should call the APN 

who would personally arrange his admission to the Fayetteville VAMC. After 

scheduling the patient’s follow-up appointment, the clerk reported telling the patient he 

did the right thing by coming in and that he could call the office any time he felt like 

talking or had any issues he wanted to discuss. 

The triage nurse saw the APN bring the patient and his wife out to the reception area 

after their appointment. She also reported hearing the APN advise the patient and his 

wife to call in the morning if they changed their minds and she would arrange 

hospitalization for him. Because the clinic normally closes at 4:30 p.m. and the doors 

were locked, the triage nurse escorted the patient and his wife to the pharmacy to get a 

prescription filled. The triage nurse reported that neither the patient nor his wife were 

crying or appeared visibly upset during this time. 

That evening the patient and his wife reportedly stayed at a motel in the Mt. Vernon area. 

The patient took the new medications and initially told his wife that he felt calmer. The 

rest of the night and the following day he seemed quiet and withdrawn. The following 

afternoon, they drove home after stopping to visit family on the way. Shortly after their 

arrival home, the patient committed suicide with a handgun. 

According to the police report (Butler County Sheriff’s Department) from the date of the 

patient’s death, the patient’s wife told the Sheriff’s deputy that after leaving the CBOC 

the day before, she asked the patient about his comment of having suicidal thoughts and 

why he had never said something to her about it. She said that he told her “that he only 

said that because he knew it was a quick way of getting the hospital to do something in an 

attempt to get faster help for his depression.” 

The coroner determined the Veteran’s death was a suicide. The toxicology results that 

accompanied the report indicated high levels of the antidepressant venlafaxine, its 

metabolite norvenlafaxine, and the antidepressant citalopram. 

VA Office of Inspector General 9 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 10 

Introduction 

Suicide is a major public health problem. In 2006, it was the eleventh leading cause of 

death in the U.S., accounting for 33,300 deaths. The overall rate was 10.9 suicide deaths 

per 100,000 people. An estimated 12 to 25 attempted suicides occur per every suicide 

death.10 Data from 2002 through 2007 indicated a rising rate of suicide attempts and 

suicides among members of the Armed Forces; firearms were the most common method 

employed.11 In a study of suicide mortality among individuals receiving treatment in the 

Veterans Health System for a diagnosis of depression, during the period from 1999-2004, 

researchers found that 0.21 percent of the Veterans meeting study criteria committed 

suicide.12

Suicidal ideation occurs in about 5.6 percent of the general U.S. population, with about 

0.7 percent of the general population attempting suicide. The incidence of completed 

suicide is lower, at 0.01 percent. Mental illness is a major risk factor, present in 90–95 

percent of suicides.13 

According to the American Psychiatric Association’s Practice 2003 Guideline for the 

Assessment and Treatment of Patients with Suicidal Behaviors, "this rarity of suicide, 

even in groups known to be at higher risk than the general population, contributes to the 

impossibility of predicting suicide."14 Mental health clinicians do not have a foolproof 

mechanism for preventing suicides, and even with good treatment, some people still 

commit suicide. For instance, 5 percent of all suicides occur in hospitals, so inpatient 

care is not absolutely preventive.15 It is therefore important to highlight the distinction 

between a good decision and a good outcome. 

Clinical decisions are made on the basis of information that is available at the time of 

evaluation and clinical disposition. In the practical reality of patient care, a good 

outcome may result from a poor decision and conversely a poor outcome may follow 

thorough evaluation and sound clinical decisions. Sources of information may include 

the history elicited from the patient; the mental status exam; the electronic medical 

record; collateral sources (e.g., family, friends) and external records both subject to the 

 

10 Centers for Disease Control and Prevention National Center for Injury Prevention and Control Web-based Injury 

Statistics Query and Reporting System (WISQARS) : www.cdc.gov/ncipc/wisqars 11 Concerns mount over rising troop suicides, CNN.com/US, February 3, 2008. 

12 Kara Zivin, PhD, H. Myra Kim, PhD, John F. McCarthy, PhD, Karen L. Austin, MPH, Katherine J. Hoggatt, PhD, 

Heather Walters, MS and Marica Valenstein, MD, MS, Suicide Mortality Among Individuals Receiving Treatment 

in the Veterans Health Affairs System: Association with Patient and Treatment Setting Characteristics, American 

Journal of Public Health, Vol.97, No. 12, December 2007. 

13 Kanapaux, William, Guidline to Aid Treatment of Suicidal Behavior, Psychiatric Times, Volume 21. No.4, July 1, 

2004. 

14 Practice Guidline for assessment and treatmentof patients with suicidal behaviors, American Psychiatric 

Association work group on suicidal behaviors, American Psychiatric Association, 2003, Washington D.C. 

15 Kanapaux, William, Guidline to Aid Treatment of Suicidal Behavior, Psychiatric Times, Volume 21. No.4, July 

1, 2004. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 11 

patient’s consent; relevant laboratory and radiologic studies; and prior interactions and 

experience with the particular patient. 

Clinical decision making takes place under varying levels of uncertainty. Decision 

making under uncertainty is particularly salient in mental health. Some patients are 

unable or unwilling to articulate their symptoms or intentions due to the nature of the 

illness they are experiencing (e.g., the psychotically depressed patient who is 

experiencing paranoid delusions). Stigma and the existence of perceived cultural and 

social norms may play a role in the patient-clinician interchange (e.g., the elderly patient 

who grew up in an era when sharing suicidal thoughts was considered taboo). Other 

patients may purposefully conceal or disguise their thoughts and intentions. Finally, 

some patients, particularly those with labile mood, mercurial temperament, or co-morbid 

substance use issues, may be absent thoughts of self harm or suicide at the time of 

evaluation; however, they may develop suicidal thoughts a few hours later with shifts in 

mood, reaction to subsequent life events or while under the influence of alcohol and 

other substances. 

Key components in the decision making process include appreciation of the multiple 

factors that may contribute to suicidal behaviors, a thorough mental health evaluation, a 

specific suicide inquiry, determination of level of risk, determination of a treatment plan, 

and relevant documentations.16

Because all patients are unique individuals, evaluation and management must occur on an 

individual basis. Patients may present with a spectrum of suicide related symptoms. 

Some present with suicidal ideation, which varies in measure depending on the 

specificity of suicide plans and the degree of intent. Patients may have active suicidal 

ideation with thoughts of harming themselves without a plan, with a vague plan, or with a 

detailed suicide plan. Patients may report passive death wishes or passive suicidal 

ideation (e.g., “I wish I could crawl into a hole and die”), but without active intent or 

plan. A patient may deny suicidal ideation at the time of evaluation, but may 

acknowledge having felt suicidal much of the previous week. Occasionally, patients may 

even report having had chronic ongoing suicidal thoughts for several years with or 

without a history of prior suicide attempts. Other patients report a history of deliberate 

self harm, such as repetitive cutting behaviors (willful self-inflicting of painful, 

destructive, or injurious acts without intent to die), with or without a history of suicidal 

thoughts or prior attempts. 

Inherent in the evaluation and management process is also the assessment of suicidal 

intent (subjective expectation and desire for a self-destructive act to end in death) and the 

lethality of suicidal behavior (objective danger to life associated with a suicide method or 

action). The lethality is distinct from and may not always coincide with an individual’s 

 

16 Jacobs, Douglas MD, Brewer, Margaret, RN MBA, APA Prctice Guideline provides recommendations for 

assessing and treating patients with suicidal behaviors, Psychiatric Annals, 34:5, May 2004, p.373-380. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 12 

expectation of what is medically dangerous. A patient may report plans to die for which 

the lethality may be low, but if the patient is intent on dying, then the clinical scenario is 

as concerning as if the plan were of greater lethality. Thus, even a patient with a lowlethality suicide plan or attempt may be at high risk in the future if intentions are strong 

and the patient believes that the chosen method will be fatal. At the same time, a patient 

with low suicidal intent may still die from suicide by erroneously believing a particular 

method is not lethal.17

“Direct questions about suicide are an essential tool in suicide assessment. The 

psychiatrist should ask specifically about suicidal thoughts, plans, and behaviors. Simply 

asking the patient about suicidal ideation and accepting a negative response may not be 

enough to determine actual suicide risk, however. Inconsistencies between a denial of 

suicidal ideation and the patient’s presentation or depressive symptomatology may 

indicate a need for additional questioning or collateral sources of information.”18

 “The goal of the suicide risk assessment is to identify factors that may increase or 

decrease a patient’s level of suicide risk, to estimate an overall level of suicide risk, and 

to develop a treatment plan that addresses patient safety and modifiable contributors to 

suicide risk.”19

Formulation of a treatment plan and a decision as to whether hospitalization is indicated 

is predicated on evaluation of multiple factors including: those listed in the preceding 

paragraph, absence or presence of prior suicide attempts, presence of acute stressors, the 

underlying psychiatric diagnosis, the presence of pain and other co-morbid, nonpsychiatric medical conditions, the presence of protective factors including familial and 

external supports, the clinician’s assessment of patient coping skills, resilience and 

vulnerabilities, the nature, presence, context, and severity of suicidal intent and suicidal 

plans, the perceived reliability of the patient, and the patient’s level of function, among 

others. After consideration of the overall scenario, the decision whether or not to 

hospitalize ultimately rests on clinical judgment. 

Treatment settings include a continuum of possible levels of care, from involuntary 

hospitalizations to partial hospital and intensive outpatient programs to more typical 

ambulatory settings. In general, patients should be treated in the setting that is least 

restrictive yet most likely to prove safe and effective. The clinician must weigh the risks 

and benefits of paternalistic considerations with patient preference regarding treatment 

venue, patient right to self-determination, and the principle of least restrictive 

 

17 Practice Guidline for assessment and treatment of patients with suicidal behaviors, American Psychiatric 

Association work group on suicidal behaviors, American Psychiatric Association, 2003, Washington D.C. 18 Jacobs, Douglas MD, Brewer, Margaret, RN MBA, APA Prctice Guideline provides recommendations for 

assessing and treating patients with suicidal behaviors, Psychiatric Annals, 34:5, May 2004, p.373-380. 

19 Jacobs, Douglas MD, Brewer, Margaret, RN MBA, APA Prctice Guideline provides recommendations for 

assessing and treating patients with suicidal behaviors, Psychiatric Annals, 34:5, May 2004, p.373-380. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 13 

environment. The benefits of hospitalization must be weighed against possible negative 

effects (e.g., disruption of employment, social stigma, fear of being in an acute 

psychiatric hospital). 

For some patients, the specter and stigma of inpatient hospitalization may deter them 

from otherwise seeking needed outpatient treatment. Other patients may present an 

imminent danger for which involuntary hospitalization is the most prudent course. Under 

certain circumstance, even in the presence of some form or degree of suicidal ideation, 

hospitalization may not necessarily be the most appropriate intervention. Given the 

multi-factorial nature of the evaluation and decision, choice of a specific treatment setting 

will not depend entirely on the estimate of suicide risk, but rather will rely on the balance 

between various factors and elements.20

While mild to moderate mental health symptoms are frequently treated in the primary 

care setting, overall, mental health specialists tend to treat patients with more complex or 

severe psychiatric symptomotology. Just as many cardiologists daily evaluate and 

manage patients with angina, mental health clinicians typically assess and treat patients 

with a range of suicidal thoughts. The presence of uncertainty, the range of clarity and 

transparence with which patients convey their inner thoughts and intents, and the role of 

stigma and other cultural factors exclude guaranteeing that the best outcome will always 

be obtained even in the presence of good assessment and seemingly good judgment. 

While the best protection against a tragic outcome is a rigorous evaluation and prudent 

clinical management, a tragic outcome does not in itself imply that a bad decision was 

made. Consequently, this inspection focused on the availability or denial of mental 

health care services, compliance with VHA policy regarding specialty referral and 

consultation, adequacy of monitoring the patient’s mental health symptoms, and the 

mental health evaluation, assessment and management, provided to this patient, rather 

than on the outcome. 

Inspection Results 

Issue 1: Denial of Care 

The patient presented to the CBOC for an unscheduled visit and was seen in the mental 

health clinic. Although the APN the patient requested to see was unavailable at the time, 

another APN in the mental health clinic volunteered to see the patient in order to 

facilitate a more timely evaluation. Review of that APN’s clinical experience reveals she 

was a licensed, APN and was also a Mental Health Clinical Nurse Specialist. Her 

resume included over 20 years experience providing mental health care. One of her 

previous roles was to screen emergency department patients to assess the need for 

 

20 Practice Guidline for assessment and treatment of patients with suicidal behaviors, American Psychiatric 

Association work group on suicidal behaviors, American Psychiatric Association, 2003, Washington D.C. 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

involuntary hospitalization. Her peer reviews and performance evaluations all indicated 

she was qualified to perform her role at the CBOC and she had no reported disciplinary 

actions. 

The complainant alleged that the patient arrived at the CBOC with a suitcase hoping to 

be admitted; he told the APN 4–5 times that he was having suicidal thoughts; that his 

anger was out of control; and that he begged to be admitted. The APN asserted that after 

the initial inquiry regarding hospitalization, the patient and his wife seemed accepting of 

the treatment plan and did not further request, beg or insist on hospitalization. The 

contemporaneous medical record documentation does not indicate multiple requests for 

hospitalization. The triage nurse and clerk noted that the patient and wife seemed to be 

pleasant and cooperative, and did not appear distraught after the visit concluded. 

Although the patient’s wife asserted that the patient brought a suitcase with him into the 

CBOC that day, the clerk, the triage nurse, the APN who evaluated the patient, and the 

pharmacist who later filled his prescription, denied the presence of a suitcase or any 

other baggage. The complainant and provider have inconsistent recollection of the 

details pertaining to the patient’s visit with the APN. We could neither substantiate nor 

refute these allegations. 

The complainant also alleged that the APN told the patient and herself that he was 

“fixable” and that they did not have the resources to admit him. Specifically, the 

complainant alleged the APN said the 15 bed inpatient mental health unit at the 

Fayetteville VAMC was full and did not have room for him. The APN acknowledged 

that earlier in the day she had learned the mental health unit at the Fayetteville VAMC 

was full. She also acknowledged that early in the visit, the patient’s wife inquired about 

hospitalization and the APN told her the mental health beds at the Fayetteville VAMC 

were full and that if he required hospitalization, they would admit him to a local hospital 

or he could be transferred to the Little Rock VAMC, located 250 miles away. However, 

the APN told us that she also told the patient’s wife that she had not yet evaluated the 

patient and it was not yet clear whether or not he would require hospitalization. The 

APN told us that she also told the patient’s wife that they needed to talk more to see what 

treatment was needed. The APN further reported that the bed status at the Fayetteville 

VAMC was irrelevant regarding whether or not to admit the patient to an inpatient 

psychiatric facility and did not factor into her decision making. 

The Chief of Mental Health Services at the Fayetteville VAMC reported that although 

the unit may have been full at the start of the day, at the time of the patient’s visit, beds 

were available on the unit. The APN who assessed the patient had experience working 

in mental health settings and in screening emergency department patients to determine 

need for inpatient psychiatric hospitalization. The APN asserted that if admission was 

indicated after the patient had been evaluated, or if the patient or his wife had said “he 

needs to be admitted,” the APN would have admitted him to a facility. Although the 

VA Office of Inspector General 14 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

patient was not hospitalized, we did not substantiate the allegation that bed availability 

was the driver for the provider’s decision to not admit the patient to a mental health unit. 

Issue 2: Quality of Care –Mental Health Assessment and Clinical Management

Assessment and Management of Clinical Symptoms 

Medical record documentation from the last visit to the CBOC indicates the patient 

reported symptoms of depression including recent feelings of worthlessness, 

helplessness, hopelessness, and feeling sad more than happy. The patient had a history 

of having had some anxiety/panic symptoms. He did not feel his medication regimen 

was working. While the patient’s history of medication adherence is unclear, notes from 

the medical record indicate that the patient reported that he began taking the citalopram 

in mid to late May. Although the patient may not have had a full trial of citalopram, in 

light of his concerns of worsening symptoms after approximately 4 weeks on the 

medication, it was not unreasonable for the APN to consider switching medications. She 

appropriately asked the patient about prior treatment response and tolerance of other 

antidepressant medications before initiating a cross taper of the citalopram and the 

venlafaxine. Because the patient reported relief of panic symptoms in the remote past 

with chlordiazepoxide, the APN prescribed temporary use of clonazepam to address 

these symptoms and discontinued the buspirone. Clonazepam is in the same family of 

medications (benzodiazepines) as chlordiazepoxide. Benzodiazepines may be used to 

provide rapid but temporary symptomatic relief of anxiety while waiting for an 

antidepressant medication to begin providing more sustained benefit. Benzodiazepines 

are used in some patients for short term symptom management, but continued, regular 

usage can result in physiologic dependence. We determined the APN’s pharmacologic 

treatment plan reasonably addressed the patient’s depressive and anxiety symptoms. 

The APN told the patient to call back if there were any problems. The APN was aware 

that the patient had an appointment with a psychologist at the CBOC’s mental health 

clinic scheduled for early the following week. Other staff reported hearing the APN 

explain to the patient that if felt he needed to be admitted the following morning he 

should call and admission would be arranged. Since clonazepan is a medication on 

which a patient could overdose, the APN asked the patient’s wife to secure the 

medication. We found a reasonable follow-up plan appears to have been initiated to 

address pharmacologic and psychologic aftercare. 

Suicide Assessment 

VA Office of Inspector General 15 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

The patient endorsed having had recent suicidal ideation. He was described as hesitant 

to disclose too much regarding this and it was unclear to the provider how often he was 

having suicidal thoughts. We could not find evidence in the medical record 

documentation that the APN further explored relevant aspects of his occasional suicidal 

thoughts (onset, chronicity, frequency, nature, intensity, and circumstance or 

precipitants). In addition, the APN did not further elucidate whether the suicidal ideation 

was passive or active in nature or whether such ideation was accompanied by thoughts 

regarding a means and/or method. 

 Access to the Patient’s Gun 

The triage nurse indicated the patient’s wife told her she had removed the weapon. 

Having reviewed this information from the triage nurse, the APN did not further inquire 

about the current location of the gun with either the patient or his wife during this 

encounter. We view this as a missed opportunity. 

Issue 3: Quality of Care – Monitoring and Referral in Primary Care 

During the course of this investigation, we determined the Mt. Vernon CBOC primary 

care service did not provide the patient with a mental health consultation within the 

required timeframe and did not adequately monitor his mental health needs. 

Timeliness of Mental Health Consultation 

The patient received a comprehensive, new patient evaluation at the Mt. Vernon CBOC 

in early April. During this evaluation, a newly hired physician documented the patient’s 

positive depression and PTSD screen, diagnosed him with depression, and prescribed 

antidepressant medication. The physician also noted the patient should receive a mental 

health consult within 14 days. However, 9 weeks passed before he received a mental 

health consultation. The consult delay occurred because the physician did not properly 

place an order for the mental health consult. 

Although the physician received a week of orientation prior to starting work at the 

CBOC, which included 2 full days of CPRS training, at the time she evaluated the patient 

she did not fully understand the CPRS consult ordering process. Within CPRS, 

physicians use check lists to allow for more efficient documentation and the physician 

believed CPRS would automatically generate a consult when she checked a box 

indicating a consult was required. However, CPRS does not automatically generate 

consults in that manner and physicians are required to use the ordering system to properly 

generate a mental health consult. Consequently, although the physician believed she had 

ordered a mental health consult, one was not properly ordered until after the patient 

called the CBOC 9 weeks later and specifically requested to be seen by the BHS. 

We found newly hired providers are not assigned mentors to perform initial chart audits 

to assure new staff are sufficiently adept with use of CPRS. At the inspection team’s 

VA Office of Inspector General 16 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

request, CBOC staff reviewed the patient records of all patients who were assessed by the 

practitioner to require a mental health consult. This review revealed the physician made 

the same inadvertent error for two other patients. We reviewed both records, the CBOC 

contacted both affected patients to arrange mental health consults, and there appeared to 

be no resulting negative outcome in either case. 

Prior to our onsite visit, CBOC leadership examined the circumstances surrounding the 

physician’s failed attempt to properly order a mental health consult and had already 

instituted a process change. Corrective action included enhancing the CPRS system. 

Now, if a practitioner documents that a mental health consult is required, a consult order 

window automatically appears on the computer screen and the physician cannot go 

forward without properly ordering a consult. 

Monitoring of Patient’s Mental Health Status at Unscheduled Primary Care Visits

The patient transferred his care to the Mt. Vernon CBOC in early April. The CBOC was 

aware this OEF/OIF Veteran had a history of depression, had recently screened positive 

for depression and PTSD, and was prescribed antidepressant medications. The patient’s 

clinical record indicates he interacted in person or by telephone at least five times 

between his initial evaluation and mental health consult, performed 9 weeks later. 

Three exchanges were telephone contacts initiated by the CBOC. These telephone calls 

were made to address non-mental health medical needs. In early April 2009, he 

presented to the CBOC for unscheduled care, requesting an EKG. During that encounter, 

he advised CBOC staff that he was not taking his prescribed antidepressants and that he 

had recently required ambulance transport to a local, private hospital emergency 

department and received care for an “anxiety attack.” A few weeks later, he again 

presented for unscheduled care and advised CBOC staff his current antidepressant was 

not effective and that he had increased the dosage without medical advice. During these 

two unscheduled, in-person exchanges to urgent care/primary care where mental health 

issues were central to the visits, staff did not make an appointment with his primary care 

physician or query his primary care physician as to whether a mental health consult 

should be initiated. There is no indication primary care staff reviewed the totality of his 

recent medical history during these exchanges or fully discussed with him the status of 

his mental health. 

We found that after the initial primary care evaluation in April, CBOC primary care staff 

missed opportunities to proactively facilitate further assessment of the patient’s ongoing 

mental health care needs. In early June, the patient himself called the BHS and requested 

a mental health consult. 

VA Office of Inspector General 17 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Conclusions 

We did not substantiate the allegation that the patient was denied hospitalization due to a 

lack of available beds at the Fayetteville VAMC. Although the patient was not 

hospitalized, we determined bed availability was not the driver for the provider’s 

decision to not admit the patient to a mental health unit. However, we could not find 

evidence in the medical record documentation that the APN sufficiently explored 

relevant aspects of his recent suicidal thoughts or further inquired about the location of 

the patient’s gun. Finally, the CBOC primary care service did not provide the patient 

with a mental health consult within the required timeframe and did not facilitate further 

assessment of the patient’s mental health when he presented to the CBOC for 

unscheduled visits with mental health issues. Although we identified these patient care 

issues, given all the facts in this case, including those relating to the care provided to this 

patient both at VA and at non-VA facilities, we cannot conclude that these deficiencies 

impacted the patient’s outcome. 

Recommendations 

Recommendation 1. We recommended that the VISN Director ensures that the Medical 

Center Director requires documented discussion in the patient’s medical record regarding 

access to lethal weapons for patient’s determined by the evaluating clinician to be at 

heightened risk for suicide. 

Recommendation 2. We recommended that the VISN Director ensures that the Medical 

Center Director requires newly hired providers are initially monitored through chart 

review to assure new staff are sufficiently adept with use of CPRS. 

Recommendation 3. We recommended that the VISN Director ensures that the Medical 

Center Director assures patients seen in the primary care clinic and who have mental 

health needs receive timely referral. 

Recommendation 4. We recommended that the VISN Director ensures that the Medical 

Center Director assures that clinical staff facilitate further assessment of patient’s mental 

health care needs for patients who present to primary care for unscheduled visits where 

mental health issues are central to the visit. 

 

VA Office of Inspector General 18 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 19 

Comments 

The VISN Director and the Medical Center Director agreed with the findings and 

conclusions. (See Appendixes A and B for the Directors’ comments.) Management 

submitted appropriate implementation plans; we will follow up until all actions are 

complete. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 20 

Department of 

Veterans Affairs Memorandum

Date: December 18, 2009 

From: Director, South Central VA Health Care Network (10N16) 

Subject: Healthcare Inspection – Alleged Denial of Care and Quality of 

Care Issues, Veterans Health Care System of the Ozarks, 

Fayetteville, Arkansas

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/KC) 

1. Enclosed is the response to the subject report. I concur with the 

recommendations. 

2. If you have any questions regarding the report, please contact 

Kathy Fogarty, Medical Center Director, Veterans Health Care 

System of the Ozarks, at 479-444-5000 or Mary Jones at the 

Network Office, 601-364-7871. 

(original signed by:) 

George H. Gray, Jr. 

Network Director 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Appendix B 

System Director Comments 

VA Office of Inspector General 21 

Department of 

Veterans Affairs Memorandum

Date: December 16, 2009 

From: Director, Veterans Health Care System of the Ozarks 

(564/00) 

Subject: Healthcare Inspection – Alleged Denial of Care and Quality of 

Care Issues, Veterans Health Care System of the Ozarks, 

Fayetteville, Arkansas

To: Director, South Central VA Health Care Network (10N16) 

Fayetteville concurs with the four recommendations made by the 

inspector general and is in the process of implementing the 

recommendations. 

 (original signed by:) 

Kathleen R. Fogarty, 

Medical Center Director 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

VA Office of Inspector General 22 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensures 

that the Medical Center Director requires documented discussion in the 

patient’s medical record regarding access to lethal weapons for patient’s 

determined by the evaluating clinician to be at heightened risk for suicide. 

Concur Target Completion Date: 3/1/2010 

Recommendation 2. We recommended that the VISN Director ensures 

that the Medical Center Director requires that newly hired providers are 

initially monitored through chart review to assure new staff is sufficiently 

adept with the use of CPRS. 

Concur Target Completion Date: Completed 

Recommendation 3. We recommended that the VISN Director ensures 

that the Medical Center Director assures patients seen in the primary care 

clinic and who have mental health needs receive timely referral. 

Concur Target Completion Date: Completed 12/10/09 

Recommendation 4. We recommended that the VISN Director ensures 

that the Medical Center Director assures that clinical staff facilitate further 

assessment of patient’s mental health care needs for patients who present to 

primary care for unscheduled visits where mental health issues are central 

to the visit. 

Concur Target Completion Date: Completed 12/10/09 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Michael Shepherd, MD 

Senior Physician 

(434) 220-8062 

Acknowledgments Stephanie Hensel, RN, JD 

Dorothy Duncan, RN, MHA, CPHQ 

VA Office of Inspector General 23 
Alleged Denial of Care and Quality of Care Issues, Veterans Health Care System of the Ozarks, AR 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Director, Veterans Health Care System of the Ozarks (564/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Christopher S. Bond, Blanche L. Lincoln, Claire McCaskill, Mark L. Pryor 

U.S. House of Representatives: Marion Berry, Roy Blunt, John Boozman, Mike Ross, 

Vic Snyder; Jo Ann Emerson 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 24