Death of a Patient, Deficiencies in Domiciliary Safety and Security, and Inadequate Contractual Agreement at the VA Northeast Ohio Healthcare System in Cleveland

The VA Office of Inspector General (OIG) conducted an inspection at the VA Northeast Ohio Healthcare System’s (the facility) Domiciliary Residential Rehabilitation Treatment Program to evaluate allegations of deficiencies in the care of a patient who died after an Emergency Department visit, as well as safety, security, and staffing at the domiciliary. In response to a congressional request, the OIG also evaluated whether Volunteers of America (VOA) met contractual agreement requirements for providing nonclinical staffing as well as food and cleaning services to the domiciliary program. The OIG did not substantiate that Emergency Department staff failed to properly assess the patient. There was not a conclusive determination that a cardiac event contributed to the patient’s death. However, the OIG found that no provider ordered an electrocardiogram prior to methadone initiation as recommended in VHA guidance. Facility leaders submitted an issue brief and conducted a review as required. The OIG determined that given the failure to obtain an electrocardiogram, facility leaders should also consider an institutional disclosure to the patient’s family. The OIG substantiated that VOA staff improperly completed health and safety round sheets. Other monitoring checks appeared to be completed as required. VOA managers stated that documentation was reviewed but accuracy was not verified. The physical security of the domiciliary building and grounds was in compliance with Veterans Health Administration requirements. The OIG determined that domiciliary nurse staffing was not unsafe because there was a minimum of two nurses on every shift along with VOA resident monitors. The domiciliary met or exceeded minimum core staffing requirements for other clinical staff. VOA substantially met its contractual obligations. The OIG made two recommendations to the VA Office of Asset Enterprise Management Director related to contract modifications, and three recommendations to the Facility Director related to electrocardiograms, institutional disclosure, and safety rounds.