‘Deficiencies’ in training, oversight, care at Overton Brooks VA; report details

SHREVEPORT, La. (KTAL/KMSS) – A new report details deficiencies found in the quality of care at Overton-Brooks Veterans Hospital in Shreveport following an investigation by the inspector general.

The Department of Veterans Affairs Office of Inspector General released a report on Wednesday, August 20, 2025, detailing findings of an investigation that was requested by Louisiana Senators Bill Cassidy and John Kennedy. The senators ordered the investigation, citing “concern regarding recent revelations of the inadequate suicide prevention policies and practices at the Overton Brooks Veterans Affairs (VA) Medical Center in Shreveport, Louisiana.”

The OIG said it conducted a healthcare inspection to gauge the quality of care provided to patients when hospitalized in the care of OBVA. The office indicated “concerns with a quality review completed after facility leaders became aware of staff’s mismanagement of a patient’s distress behavior.”

The report listed deficiencies with clinical management of a patient hospitalized for care, including “a physician who lacked a complete understanding of the patient’s diagnosis and clinical response to a medication” before discontinuing the treatment. They further report that staff members mismanaged the patient’s distressed behaviors, specifically by not implementing one-to-one observation per policy; and not activating a behavioral patient record flag, or using the electronic health record to communicate between medical disciplines, also a violation of the Veterans Administration Policy.

The OIG made five recommendations for OBVA, including:

• Comprehensive reviews of the patient’s hospitalization and taking actions as indicated, including quality management processes such as a peer review.
• The director should ensure that medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records. They should assess the current processes for obtaining these records, identify any barriers to completion, and take the necessary actions.
• The director should assess the application of the one-to-one observation policy and practices at the facility and take the necessary action.
• The director will review the interim behavioral patient record flag processes to ensure safety strategies for staff and patients are implemented.
• Overton Brooks VA Medical Center Director will evaluate whether documentation of patient and patient-related behavioral events is reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff, and take action as necessary.

The report concluded by saying that the Overton Brooks VA Medical facility director concurred with the recommendations made by the OIG.