Alleged Inadequate Mental Health Treatment at the Dayton VA Medical Center, Ohio

The VA Office of Inspector General (OIG) conducted an inspection of the Mental Health Residential Rehabilitation Treatment Program (MH RRTP) at the Dayton, Ohio, VA Medical Center (Facility) to assess allegations regarding the care of a resident who died approximately 36 hours after MH RRTP admission. The OIG did not substantiate that staff failed to treat the resident’s MH and addiction problems. The OIG found an absence of one Clinical Institute Narcotic Assessment but was unable to determine if the presence of this score would have altered the course of events. The OIG was unable to substantiate or not substantiate that the resident died by a suicidal act. Although the evidence indicated it was unlikely the resident died by a suicidal act, the OIG could not definitively determine the resident’s intentions. The OIG did not substantiate Facility staff failed to assign a counselor to the resident; however, counseling staff did not meet with the resident or provide a therapeutic activity schedule. The OIG substantiated medications were prescribed for the resident’s opioid withdrawal management consistent with care management and admission assessments. The OIG determined Facility leaders completed required administrative reviews following the resident’s death. Facility managers implemented new screening and admission processes, established a resident privilege levels program, and initiated a plan to increase Medication Assisted Treatment accessibility. However, the OIG determined that MH RRTP staff did not provide information regarding the privileging levels program to residents prior to admission and also identified concerns about whether the privileging levels program was congruent with MH RRTP goals of rehabilitation and recovery. The OIG made three recommendations related to clinical scales for opioid use withdrawal symptoms, timely therapeutic activity schedules, and residents’ privileging levels program.