Healthcare Inspection – Unexpected Patient Death in a Substance Abuse Residential Rehabilitation Treatment Program, Miami VA Healthcare System, Miami, Florida

The VA Office of Inspector General Office of Healthcare Inspections conducted a review of an unexpected patient death in the substance abuse residential rehabilitation treatment program (SARRTP) at the Miami VA Medical Center, part of the Miami VA Healthcare System. We found that a patient died in his room in the SARRTP, and autopsy results indicated the patient died from cocaine and heroin toxicity. This patient had a history of multiple positive urine drug screens while in the SARRTP. We found that the SARRTP security surveillance camera was not working at the time of the patient’s death, was still not working at the time of our site visit, and no alternative arrangements were made to monitor patients in the absence of an operational camera. We found that evening, night, and weekend SARRTP staff often sat in a back room where they had an extremely limited view of the unit and no view of the unit’s entrance/exits. We also found that staff were not consistent in their methods of contraband searches and did not monitor patient whereabouts or unit visitors as required. VHA mandates that there be one staff member on the SARRTP unit at all times. We found that staff were not present at all times as required. We reviewed the electronic health records of other SARRTP patients to determine the frequency of illicit substance use among program participants. Not including potential false positives due to prescribed medication, we found that 7 of 21 patients had a positive urine drug screen or breathalyzer test while in the SARRTP. We concluded that the current system of surveillance and supervision of patients did not adhere to VHA policy. We made four recommendations.