Patient Overdose Death in a Residential Rehabilitation Treatment Program at a VISN 1 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review circumstances surrounding a Residential Rehabilitation Treatment Program patient’s death from heroin overdose at a Veterans Integrated Service Network (VISN) 1 medical facility (facility). The OIG determined that protocols were not in place for initiating patients’ medication-assisted therapy. At the time of the patient’s death, a specific protocol was not in place to start patients on Suboxone®, a medication that assists with reducing opioid withdrawal symptoms. Five facility providers said they did not know or could not articulate the process for a patient to obtain Suboxone® therapy. Additionally, a formal Standard Operating Procedure or policy regarding tracking patient no-shows to an off-site substance abuse day program was not in place. The OIG also found Veterans Health Administration’s (VHA) urine drug testing policy was not followed when staff failed to collect the patient’s urine specimen. The facility amended its urine drug testing practice after this patient’s death. An emergency response team was called when the patient was found unresponsive, but resuscitation attempts were not initiated due to medical futility. The Cardiopulmonary Resuscitation Committee did not initially review documentation related to the patient’s death because treatment was not initiated. According to VHA policy, facilities are only required to review events where resuscitation was attempted. While the facility had process deficiencies, the OIG could not determine how or to what extent the deficiencies contributed to or had impact on the patient’s death. The OIG made three recommendations related to medication-assisted therapy initiation, no-show policies, and staff training on no-show procedures.