An Inspector General has cleared the Dayton VA Medical Center’s Mental Residential Rehabilitation Program of blame after a veteran with a history of opioid use disorder was found unconscious in a locked bathroom stall on the VA campus and dying in early 2017.
The resident, whose identity and even gender were not identified in the 40-page report released by the VA’s Office of Inspector General, had been treated as an outpatient at the center but admitted to the Mental Rehabilitation Program as an inpatient 36 hours before, the person had taken a walk but did not return. When the veteran’s father came to the center to bring blankets, the veteran could not be found. The veteran was later found in a bathroom on the campus with blood and vomit on the patient’s nose, mouth and clothes, a plastic bag with capsules in a pocket and capsules scattered on the floor. VA staff tried to resuscitate the patient but were unsuccessful.
On April 11, 2017, a caller called the Office of Inspector General hotline and complained that the Dayton VA had failed to treat the veteran’s mental health and addiction problems, thus spurring the patient to die by suicide.
The Office of Inspector General investigated, but found that the VA “provided appropriate overall management” to the patient during the 47 days the patient was treated, including as an outpatient and later through the residential program. The inspector general also was unable to substantiate whether the patient committed suicide, adding that the patient denied thoughts of self-harm during treatment both as an outpatient and after being admitted to the residential program. Staff, the report concluded, “completed required suicide risk assessments and determined” that the resident “was not at high risk for suicide.” The coroner ruled the death an accident.
The inspector general also could not substantiate claims the residential staff did not assign a counselor to the veteran. Instead, it found, the center assigned an interdisciplinary team that included counselors. Counselors did not, however, meet with the veteran on the day of the veteran’s admission but was prescribed medications to manage withdrawal symptoms.
After the veteran’s death, the inspector general found, the VA implemented new screening and admission processes and established a program that allowed residents earn privileges such as cell phone possession based on their number of days adhering to the center’s rules. The inspector general recommended new scales to assess the severity of withdrawal symptoms, that the residential program provides timely therapeutic activity schedules to residents and further evaluate the effectiveness of the center’s residential privileges program.