Healthcare Inspection – An Unexpected Death in a Mental Health Treatment Program, VA New Jersey Health Care System, Lyons, New Jersey

OIG Office of Healthcare Inspections conducted an inspection in response to a request by the OIG Office of Investigations to review the care of a patient who died unexpectedly while residing at the Mental Health Residential Rehabilitation Treatment Program (MH RRTP) at the VA New Jersey Health Care System (facility), Lyons, NJ. The Office of the State of New Jersey Medical Examiner’s autopsy report listed “Acute intoxication due to the combined effects of cyclobenzaprine, tramadol, gabapentin, sertraline, hydroxyzine, and amlodipine” as the cause of death. The manner of death (suicide, homicide, accidental) was listed as undetermined and final diagnoses included hypertensive and atherosclerotic cardiovascular disease. We found that program staff did not comply with Veterans Health Administration and facility requirements for an effective safe medication management program or document the resident’s care sufficiently or timely. We also found that leadership did not provide sufficient professional support for a MH RRTP advanced practice registered nurse (mid-level provider). We recommended that the Health Care System Director ensures that the facility complies with MH RRTP safe medication management requirements, completes required electronic health record documentation, and provides appropriate follow-up to requests for professional support by MH RRTP mid-level providers.