United States Government Publishing Office publisher pbl distributor dst United States Government Accountability Office Human Resources Division author aut Government Organization text government publication eng GAOREPORTS Legislative Agency Publications gao legislative 2010-08-12 U.S. Government Printing Office 1993-12-10 monographic deposited born digital GA 1.13:HRD-94-27 https://www.govinfo.gov/app/details/GAOREPORTS-HRD-94-27 P0b002ee18038f614 f:hd94027 DGPO 2010-08-12 2011-03-24 GAOREPORTS-HRD-94-27 machine generated eng fdlp REPORT GAOREPORTS-HRD-94-27 HRD-94-27 Veterans hospitals Mental care facilities Patient care services Mental health care services Physicians Medical records Hospital administration Health care personnel Monitoring Information dissemination operations Letter Report HRD After two patients were found dead on the grounds of a Department of Veterans Affairs (VA) medical center, GAO investigated and found that "high risk" patients--those unable to care for themselves--who wander away are a significant problem at 39 of 158 VA medical centers. In a recent 2-year period, more than 100 searches were conducted for high-risk patients at 20 VA medical centers. Patients leave their treatment settings without staff knowledge primarily when medical center staff (1) underestimate the potential for these patients to wander off without authorization or (2) fail to closely watch all high-risk patients while they are in the facility or on its grounds. During the same 2-year period, about 7,000 searches were conducted throughout the VA system for high-risk patients who were reported missing. About 99 percent of these patients were ultimately found unharmed; 34 were found dead and 19 injured. VA is working to develop search procedures for these high-risk patients who disappear without staff knowledge and approval. The goal is to find these persons before they leave the medical center grounds. But VA also needs to do a better job of monitoring high-risk patients to prevent unauthorized departures in the first place. Further, VA can do more to locate unaccounted-for patients. https://www.govinfo.gov/content/pkg/GAOREPORTS-HRD-94-27/html/GAOREPORTS-HRD-94-27.htm GAO/HRD-94-27 https://www.govinfo.gov/app/details/GAOREPORTS-HRD-94-27 Letter Report GAO/HRD-94-27; VA Health Care: VA Medical Centers Need to Improve Monitoring of High-Risk Patients; Veterans hospitals Mental care facilities Patient care services Mental health care services Physicians Medical records Hospital administration Health care personnel Monitoring Information dissemination operations