Following veteran's overdose death, report finds problems at Miami VA drug rehab program
By DANIEL CHANG | The Miami Herald | Published: April 2, 2014
A drug abuse rehabilitation program at Miami’s Veterans Affairs hospital failed to monitor patients, provide sufficient staff, control access to the facility or even curb illicit drug use among patients — culminating with the death of a combat veteran in his 20s who overdosed on cocaine and heroin, according to a federal report.
According to the report issued last week by the agency’s Office of Inspector General, investigators found security lapses including broken surveillance cameras and inconsistent searches for contraband. Staff members were frequently absent or in a back room instead of monitoring patients in the drug abuse rehabilitation unit on the fifth floor of the Miami VA Medical Center.
Patients in the program were allowed to sign out of the Miami facility unsupervised, with potentially easy access to illicit drugs, according to the report.
And investigators reported that, in addition to the patient who died of an overdose, seven of 21 patients in the program had tested positive for drug or alcohol use at some point during their stay.
The report did not name the veteran who died of the overdose or give a date. Nor did it provide specifics about the veterans who tested positive for drugs. It did not say whether anyone responsible at the Miami VA has been fired, demoted or reprimanded as a result of the report.
Shane Suzuki, a public affairs officer for the Miami VA Healthcare System, issued a written statement calling the report’s findings on the program and patient overdose “administrative or related to the environment of care and would not have prevented this incident.”
He added: “An action plan has been developed and completed on all OIG recommendations.’’
Suzuki said the federal facility’s supervisors concur with the investigative report’s recommendations for improvements: repairing surveillance cameras, staffing appropriately and having supervisors aggressively monitor patients for illicit drug use.
The investigative findings elicited a rebuke of the VA by U.S. Sen. Bill Nelson (D-Fla.), who issued a written statement Tuesday emphasizing that patient care should be the agency’s “top priority.”
“That’s why there are a number of inspector general probes of VA hospitals, including the Miami drug rehabilitation center,” Nelson wrote. “Some of the things that have been found are really unacceptable and in some cases terribly tragic.”
The Miami facility is part of a regional network of Veterans Affairs hospitals that have come under increased scrutiny from elected officials following a Tampa Tribune report in February about five cancer patients who died because of long waits and delayed care — and a lack of answers about where those deaths took place.
On March 28, Nelson called upon the Secretary of Veterans Affairs, retired U.S. Army Gen. Eric Shinseki, to provide greater “transparency” regarding the deaths.
Gov. Rick Scott also issued a call Tuesday for the state’s Agency for Health Care Administration to inspect federal VA hospitals, including the Miami facility.
It is unclear whether state officials have the legal authority to inspect VA hospitals without the federal government’s consent, but AHCA Spokeswoman Shelisha Coleman said the agency shares the governor’s concerns.
“We are currently developing a plan and schedule to assess the hospitals’ processes and procedures,” Coleman said in an email to the Herald.
Miami’s VA hospital came under intense scrutiny in 2009 when it was revealed that nearly 2,500 veterans might have been exposed to HIV and other illnesses during colonoscopies performed with improperly cleaned equipment.
That incident led to the removal of the hospital director, and lawsuits filed by affected veterans.
Problems documented in the recent OIG report focused on the Miami VA hospital’s drug abuse residential rehabilitation program, with 24 beds dedicated to treat veterans for alcohol and drug abuse.
Patients are allowed to leave the program on a pass, including overnight and weekends, to tend to personal affairs. They also are allowed to leave the program without a pass, for up to two hours, but must report their destination, remain on campus and sign in upon return.
However, investigators found that Miami VA staff members were not reviewing the sign in/sign out logs for suspicious activity patterns, and that patients were not consistently following procedures. Entries on the logs also did not include dates, according to the report.
The patient who overdosed was a combat veteran of Operation Enduring Freedom in Afghanistan diagnosed with multiple substance dependence, post-traumatic stress disorder (PTSD), sleep apnea, mood disorder and traumatic brain injury, according to the report.
He was admitted to the Miami VA’s psychological rehabilitation program in 2012, and tested positive for illicit drug and alcohol use numerous times while there.
In early 2013, according to the report, the patient was transferred to the PTSD rehabilitation program. A month later, he tested positive for cocaine, and the following month he tested positive for cocaine and alcohol, the report states.
The patient then was transferred to an inpatient mental health unit, according to the report, and several days later he was admitted to the drug abuse rehabilitation program, where he again tested positive for cocaine.
He was placed on restriction with no overnight or weekend passes for three weeks. But he was allowed to leave for up to two hours without a pass, the report states.
The day before his death, the patient left the drug rehabilitation program in the early afternoon and returned that evening, the report states. He tested negative for alcohol use, according to the report.
However, other patients interviewed by OIG investigators reported that the patient had been high on drugs and needed help getting into bed.
He was found dead in his room the next morning. Official cause of death: acute cocaine and heroin toxicity.