Poor oversight and failures in testing procedures led to two non-fatal fentanyl overdoses last year at a VA residential treatment program in upstate New York in which patients acquired the potent synthetic drug from another veteran at the facility, the VA's Office of Inspector General reported Wednesday.
In a similar report in July, the IG found that lax oversight and poor communication among staff were factors in the overdose death of a patient at another unidentified VA residential drug treatment program in 2015. That patient was found dead in a locked bathroom. An autopsy attributed the cause of death to a heroin overdose.
In the case at the Bath, N.Y., VA Medical Center's treatment program, Matthew Helmer, 34, of Hyde Park, N.Y., a resident in drug treatment, was charged in October 2017 with felony counts of drug possession by federal prosecutors, who alleged that he was a "runner" for other veterans in the program, the local Star-Gazette newspaper reported.
In court documents, a VA investigator said Helmer told him that "he knew that [patients] overdosed and were currently in the hospital," but was unaware of how they acquired the synthetic opioid fentanyl, the newspaper reported.
Drug paraphernalia was found in Helmer's room and he acknowledged that heroin was his own drug of choice, the newspaper said.
The IG's report focused on the 170-bed Domiciliary Residential Rehabilitation Treatment Program (DRRTP) in Bath, a town in New York's "southern tier" near the Pennsylvania border.
The DRRTP is part of the Bath VA Medical Center, the VA's oldest health care facility. The Bath facility was set up in 1865 as the National Home for Disabled Volunteer Soldiers returning from the Civil War. It currently serves about 13,000 veterans in the region.
The IG's report noted that "the Veterans Health Administration does not require treatment programs to routinely test for illicit drugs, such as fentanyl, that are trending in the community."
Following the two non-fatal fentanyl overdoses, the Bath center changed its urine drug screening (UDS) methods to include testing for the presence of fentanyl, but the tests went to "a non-VA laboratory with a turnaround time that compromised the timeliness of clinical intervention and overdose prevention," the IG report found.
The result was that "the OIG determined that the facility's fiscal year 2017 positive UDS tracking data was inaccurate."
The report also cited Bath center staff as saying that urine screening results were not properly recorded.
The residential treatment program then went to a system in which "color-coded stickers" were placed on the doors to the rooms of residents with a history of opioid use who were believed to be at high risk for suicide, the IG's report said.
The sticker system was discussed at meetings, but "key staff reported being unaware of its use for residents at high risk for suicide," said the 37-page report by Dr. John D Daigh Jr., assistant Inspector General for Healthcare Inspections.
The report also found that staff at the residential treatment program "did not have sufficient personal protective equipment or training to safely conduct contraband searches of residents' rooms and belongings."
It cited several case studies at the Bath treatment program indicating that drugs including fentanyl were available for those who wanted them.
In the case of a veteran identified as "Resident B," who had recently completed an in-patient program for opioid detoxification, a routine urine test taken 15 days after he became a Bath resident was positive for opioids. On the 19th day, a search of Resident B's room "produced a baggie of unknown pills, a small orange cap with unidentified powder in it, a knife with a blade longer than three inches, straight razor blades, a needle, and a packaging wrapper for suboxone," the report said.
Another urine test was positive for the presence of fentanyl. "On Day 20, Resident B declined discharge planning and was discharged irregularly," the case study said.
In response to the IG's report, Dr. Joan McInerney, director of the VA's New York/New Jersey Health Care Network, concurred with the findings and pledged action to correct deficiencies.
"The Veterans Integrated Service Network will conduct an evaluation of the Bath VA Medical Center processes for fentanyl test results, turnaround times and notification of results. Appropriate action will be taken based on the process evaluation result," McInerney said in a statement.
In the case of the veteran's overdose death in 2015, the IG's report in July found that staff at the unidentified residential treatment program failed to take a number of steps that might have resulted in an intervention.
The patient had refused, or claimed the inability to provide, a urine sample, the report said. In that circumstance, "staff were required to review the appropriateness of residential care to determine whether the patient should continue in the program and, if so, under what conditions. For this patient, no documented action was taken," the report said.
On a Monday morning, a registered nurse on staff found "that the patient appeared to be sweating, had tremors, and was less engaged in treatment. That afternoon, a program psychologist met with the patient."
"The psychologist stated in an interview the patient 'was doing really well in the program' and that there was not anything that stood out to indicate the patient was using drugs or suicidal," the report said. "The next day, the patient entered a single-room public bathroom on the main floor of the facility, which could be locked from within.
"Later that evening, the patient was discovered unresponsive in the bathroom by a maintenance staff member. A Code Blue was initiated; however, the Code Blue team was dispatched to the wrong area," the report said. "They subsequently arrived at the correct location, assessed the patient, and determined that resuscitation was futile because the patient appeared to have been dead for several hours."
The abuse of fentanyl and other opioids has been singled out by President Donald Trump as a main factor in the suicide rates of the civilian and veteran populations.
In July, the Justice Department reported that the number of federal fentanyl prosecutions has more than tripled, from 74 defendants in 51 cases in fiscal 2016 to 267 defendants in 181 cases in fiscal 2017.
"This crisis is devastating," U.S. Attorney General Jeff Sessions said in Concord, New Hampshire, on July 12. "But we will not stand by idle. We are not going to accept the status quo. We will not allow this to continue."
-- Richard Sisk can be reached at Richard.Sisk@Military.com.
