Inspector General faults Sioux Falls VA on suicide prevention

Veterans at risk for suicide didn't receive screenings within required timeframe; hospital took steps to rectify

Staff at the Royal C. Johnson Veterans’ Memorial Hospital in Sioux Falls were falling short in a key metric to prevent suicide among veterans, according to both an internal review and an unannounced inspection earlier this year.

The review found suicide risk assessments were not being conducted on a statistically significant number of veterans who tested positive for risk during suicide screenings. VA policy states that veterans who do screen positive should receive a Comprehensive Suicide Risk Assessment the same calendar day.

But one in four veterans who did screen positive were not being assessed, well short of the VA’s benchmark. That was a major finding of the inspection conducted by the VA’s Office of Inspector General.

“Failure to complete this evaluation within the time frame poses a potential patient safety risk because patients with suicidal thoughts and behaviors might go unnoticed and untreated as a result,” according to the inspection report.