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Report criticizes Southern Nevada VA handling of vet threat to worker

Updated July 22, 2020 - 8:41 am

A veteran who swung a wrench at a North Las Vegas VA social worker last year was not arrested for nearly two months because the agency delayed in reporting the incident to local police, a newly released federal investigation found.

VA Southern Nevada Healthcare System leaders also did not notify the social worker for another two weeks that the patient had threatened to kill the employee, according to the Department of Veterans Affairs Office of Inspector General report released last week.

Managers also failed to address the worker’s mental health needs after the attack, the health care inspection report found, concluding that the VA lacked clear policies to respond to “emotional and mental health injuries.”

VA police also did not log the attack in the veteran’s electronic health record until 46 days after the incident, a failure of their duties, the report states.

“It is imperative that VA police be more than passive participants in the Disruptive Behavior Reporting System process,” the report said.

Veteran pleads guilty

The unidentified veteran pleaded guilty to an unspecified offense nearly four months after the incident, the report states. He or she was previously incarcerated for violent offenses, including assault, and has a history of mental health issues, the report says.

“The safety of our staff and veterans is paramount to being a high-reliability organization,” VA medical center’s spokesman Chuck Ramey said in a statement, adding that the facility has a zero-tolerance policy for disruptive behavior.

“(We) will immediately respond accordingly to any verbal or physical threats, while providing for the health and welfare of our employees.”

The assault happened in spring of 2019, when a social worker, referred to as “Social Worker A” in the report, visited the veteran’s apartment to discuss the veteran’s government-assisted housing.

After receiving no response at the veteran’s apartment, the social worker left a card and note and was walking back to a car when the veteran approached with metal socket wrenches in each hand. The veteran began calling the social worker a “liar” and swung one of the wrenches at the employee’s head.

A socket dislodged from one of the wrenches but did not strike the social worker.

The employee then retreated to the car and locked the doors, and the patient approached the car and swung a wrench toward the window, but did not hit the car, the report said.

The report does not state whether the social worker was physically injured. The employee notified a supervisor and VA police of the attack and filed a report with the Metropolitan Police Department the next day.

Local police not alerted to homicidal threat

Three weeks after the assault, another social worker heard that the patient “expressed wanting to kill Social Worker A,” the report said. That employee notified a VA supervisor of the threat, but the report states Social Worker A, who was on leave at the time, wasn’t notified of the threat until two weeks later.

Local police were never alerted of the homicidal threat, the report states, because of a communication failure between the VA police and the social worker’s supervisor.

“Community police arrested the patient based on the assault warrant; they were unaware of the threat or possible ongoing danger to Social Worker A at the time of the arrest,” the report said. “Had the community police known about the threat at an earlier date, an arrest may have occurred sooner.”

The report also noted that, because of understaffing, social workers at the facility are often unable to take a colleague with them on patient home visits if needed for safety concerns.

Southern Nevada Healthcare System Director William Caron wrote, in response to one of the six recommendations from the inspector general’s office, that 35 out of 39 social worker positions had been filled.

He also wrote that a safety committee had been formed and that VA supervisors and staff were retrained on the agency’s safety and security requirements and will be tested on them annually.

Additional provisions also have been taken to ensure a “timely review of cases and behavioral flags,” as well as facilitating more communication between staff, VA police and community police.

Contact Briana Erickson at berickson@reviewjournal.com or 702-387-5244. Follow @ByBrianaE on Twitter.

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