SHREVEPORT, La. — A new report from the Department of Veterans Affairs Office of Inspector General (OIG) has found multiple deficiencies in patient care and safety oversight at the Overton Brooks VA Medical Center in Shreveport.
The review stemmed from a case in early 2024 in which a patient’s medication and behavioral management were mishandled. Investigators said a hospitalist discontinued the medication olanzapine without fully reviewing the patient’s medical history, consulting specialists, or developing a treatment plan. The mismanagement, coupled with the staff’s failure to properly address the patient’s escalating distressed behaviors, may have contributed to assaults on three individuals.
OIG found that staff did not follow established Veterans Health Administration (VHA) policy by failing to:
- Implement required one-to-one observation,
- Activate a behavioral patient record flag to trigger safety measures, and
- Use the electronic health record to communicate the severity of the patient’s behaviors across disciplines.
While facility leaders identified concerns with the patient’s care, OIG determined that quality management reviews, such as a peer review, were never completed — leaving potential care improvements unaddressed…