How long does a patient at the Lyons  VA have to be dead, before any of the staff notices it, let alone cares about it?

Lyons NJ VA Doesn’t Notice When Psych Patients Leave Hospital to Buy Heroin.

so it shouldn’t surprise anyone that they didn’t notice the patients using the heroin when they returned to their rooms, or that the VA Lyons staff didn’t notice that one veteran had died in his room for at least 12 hours and maybe as long as 36 hours.

On August 9, 2012 the USA Attorney’s office in Newark announced the  arrest and indictment of Ryan Kreiger. Kreiger  was hospitalized in the post-traumatic stress disorder ward of the VA Medical Center in Lyons, N.J. On July 1, Kreiger and another patient left the Lyons VA, traveled to Patterson N.J. where they purchased heroin. They returned to the VA  where they and another veteran used the heroin, in one of their rooms.One veteran died as a result of  an  overdose on July 2, 2012.

It is not clear when anyone at the VA realized that one of the patients had died. The complaint indicates that they used the heroin in the early hours of July 2, 2012 and state “A Hospital staff discovered J.Z.’s dead body in his room the following afternoon. ” Does following afternoon mean on July 2, 2012 or does it mean July 3, 2012? While it is horrible that  that two patients left the VA hospital to purchase heroin, and it is certainly appropriate to consider criminal charges against Kreiger, one seriously has to wonder why there have not also been criminal charges against the VA employees who were responsible for watching these patients. Let’s remember that these patients were presumably there, because they had mental issues. Someone was supposed to be in charge of these veterans. Someone should have noticed that they were gone for several hours. Someone should have searched them when they returned to VA Lyons campus, someone should have noticed that they were using heroin in one of their rooms, and one should have noticed that one of them was dead for either 12 hours or 36 hours.The VA’ s Patient Handbook clearly  indicates that patients are not supposed to leave the ward unless it has been approved of by the Nurse in Charge. Similarly the patients are required to be present for nursing shift changes, mealtimes and medication. It is astounding that someone at the VA did not notice that a patient had died for at least 12 hours and probably 36 hours.

The normally verbose VA Public Affairs office seems to have not made any statements at all about this incident. The VA OIG’s press release on its website is essentially a link  to the US Attorney’s Office. Unfortunately, this is not the first time that  a death of a veteran at the Lyons VA has been investigated in a less than enthusiastic manner:

 

THe VA’s Patient handbook states:

Absence from Ward

The Nurse in Charge must know whenever you leave the ward. You must sign in and out in the log located at the nurses’ station. Visiting patients on other wards is permitted only on nonrestricted wards, during regular visiting hours, and not during a bingo or ward party. Patients are to be on their wards by 10 p.m., and remain there until 6 a.m. It is important that you remain on your assigned ward during doctor’s rounds, nursing change of shift rounds, mealtime, and medication/treatment time. At East Orange, inpatients must be escorted below the third floor. See the Head nurse for any exceptions you may need.

 

The VA’s Patient handbook states:

Absence from Ward

The Nurse in Charge must know whenever you leave the ward. You must sign in and out in the log located at the nurses’ station. Visiting patients on other wards is permitted only on nonrestricted wards, during regular visiting hours, and not during a bingo or ward party. Patients are to be on their wards by 10 p.m., and remain there until 6 a.m. It is important that you remain on your assigned ward during doctor’s rounds, nursing change of shift rounds, mealtime, and medication/treatment time. At East Orange, inpatients must be escorted below the third floor. See the Head nurse for any exceptions you may need.

August 9, 2012

NEWARK, N.J. – An Iraq war veteran was arrested this morning for allegedly giving heroin to a fellow veteran at a U.S. Department of Veterans Affairs hospital who died of an overdose, and for obstructing the investigation into the death, U.S. Attorney Paul J. Fishman announced.

Ryan Krieger, 28, a former Marine and in-patient resident at the post-traumatic stress disorder ward of the VA Medical Center in Lyons, N.J., was charged by Complaint with distribution of heroin and obstruction. He made his initial appearance today before U.S. Magistrate Judge Cathy L. Waldor in Newark federal court.

According to the Complaint:

On July 1, 2011, Krieger and the overdose victim, identified as “J.Z.,” called a taxi and snuck out of the VA Hospital to buy heroin in Paterson, N.J. They withdrew $500 from J.Z.’s bank account at an ATM machine, and Krieger purchased the heroin from a drug dealer he knew in Paterson. When Krieger and J.Z. returned to the hospital with the heroin, they were joined by another in-patient resident, identified as “R.C.,” and the three of them used the heroin in J.Z.’s room.

In the early hours of July 2, 2011, Krieger, J.Z., and R.C. were continuing to use heroin in J.Z.’s room when J.Z. collapsed and lost consciousness. The Complaint alleges that neither Krieger nor R.C. notified anybody at the VA Hospital. Hospital staff discovered J.Z.’s body in his room the following afternoon. He had died of a heroin overdose. Special agents with VA’s Office of the Inspector General (“VA-OIG”) began an investigation into the circumstances of his death.

Krieger allegedly lied to VA-OIG investigators about his activities on the night of J.Z.’s death, and only admitted his role upon being confronted with physical evidence, including a surveillance video from the ATM machine in Paterson. While he agreed to cooperate with the investigation, he allegedly told an individual at the VA hospital months later that he had administered the heroin to J.Z., and that when J.Z. appeared to overdose, Krieger did not seek help, but propped J.Z. up in his bed to create the appearance that J.Z. had taken the heroin himself and overdosed by himself.

The criminal complaint:

I, Robert Breunig, a Special Agent with the u.S. Department of Veterans Affairs, Office of the Inspector General (“VA-OIG”),having conducted an investigation and having spoken with other individuals, have knowledge of the following facts. All dates and times are approximate, and all conversations and statements are related in substance and in part:
1. In July, 2011:
a. The defendant, RYAN KRIEGER (“defendant KRIEGER”), was a military veteran and in-patient resident at the post traumatic stress disorder (“PTSD”) ward of the u.S. Department of Veterans Affairs (“VA”) Medical Center in Lyons, New Jersey (the”VA Hospital”) .
b. R.C. was a military veteran and in-patient resident at the PTSD ward of the VA Hospital.
c. J.Z. was a military veteran and in-patient resident at the PTSD ward of the VA Hospital.
2. On July 1, 2011, defendant KRIEGER and J.Z. called a taxi and snuck out of the VA Hospital to buy heroin in Paterson, New Jersey. Once in Paterson, they withdrew $500 from J.Z.’s bank account at an ATM machine, which was captured on surveillance video, and defendant KRIEGER purchased the heroin from a narcotics dealer in Paterson who had supplied defendant KRIEGER with heroin in the past. When defendant KRIEGER and J.Z. returned to the hospital with the heroin defendant KRIEGER had purchased, they were joined by R.C., and the three of them used the heroin in J.Z.’s room.
3. In the early hours of July 2, 2011, defendant KRIEGER,J.Z., and R.C. continued to socialize and use heroin in J.Z.’s  room. J.Z. was speaking on his cellular phone with his girlfriend, A.E., while defendant KRIEGER and R.C. were watching
videos and talking. Suddenly, J.Z. collapsed and lost consciousness. Neither defendant KRIEGER nor R.C. notified anybody at the VA Hospital.
4. VA Hospital staff discovered J.Z.’s dead body in his room the following afternoon. The positioning of the body led special agents with VA-OIG (the “Agents”) to investigate the possibility of a suicide. New Jersey’s Office of the State Medical Examiner later determined that the cause of death was~acute heroin intoxication.”
5. The Agents interviewed A.E., who stated that, while speaking with J.Z. on the phone, she heard a crashing sound followed by cries in the background of, “Jay! Wake up! Wake Up!” The Agents also reviewed surveillance camera video from the  PTSD ward on the dates set forth above, and they determined the defendant KRIEGER and R.C. had entered and exited J.Z.’S room both before and after J.Z.’s collapse, as measured by A.E.’s estimate of the time.
6. Upon being questioned by the Agents on August 11, 2011, concerning the events surrounding J.Z.’s death, defendant KRIEGER told material lies about his activities on the night of J.Z.’s
death, including that he was smoking cigarettes with J.Z. and never left the building. When he was confronted with contradictory facts, such as surveillance video of R.C. and him withdrawing money in Paterson, he recanted and admitted to the
conduct and events set forth above. Defendant KRIEGER then agreed to cooperate with the Agents’ investigation.
7. In the autumn of 2011, defendant KRIEGER spoke with a cooperating witness (the “CW”) on the campus of the VA Hospital. According to the CW, defendant KRIEGER admitted to the CW that he
engaged in the conduct set forth above, but defendant KRIEGER additionally said that he had administered the heroin to J.Z., and that when J.Z. appeared to overdose, defendant KRIEGER had propped J.Z. up in his bed, in lieu of going for help, to create the appearance that J.Z. had taken the heroin himself and overdosed by himself.
8. Defendant KRIEGER has ceased cooperating with the investigation insofar as he has ceased attending appointments and programs at the VA Hospital, failed to make himself available to the Agents, and changed his address without notifying the VA.

 

 

This would not be the first  time Kenneth Mizzach Director of the VA NJ Health System was not particularly aggressive in investigating and holding employees responsible after a patient died at the Lyons VA. The VA’s own Office of Inspector General expressed its concerns about how he handled the investigation into another death of another patient who also went missing at the Lyons VA:

REVIEW OF THE RELIABILITY OF AN ADMINISTRATIVE BOARD OF INVESTIGATION CONCERNING A PATIENT SEARCH AND RECOVERY VA NEW JERSEY HEALTHCARE SYSTEM, LYONS CAMPUS REPORT NO. 9PR-A01-110
(9IQ004HQ)
INTRODUCTION
Purpose
The Office of Inspector General (OIG) reviewed the reliability of an Administrative Board of Investigation (Board) into the search for a patient and the recovery of his body at the Lyons Campus of the Department of Veterans Affairs (VA) New Jersey Healthcare System. The OIG’s Administrative Investigations Division and the Office of Healthcare Inspections conducted the review at the request of Congressman Rodney P. Frelinghuysen. Congressman Frelinghuysen expressed concern about the accuracy and thoroughness of the Board, including issues involving the patient’s supervision prior to his disappearance, the length of time that elapsed before Lyons officials initiated a search for him, and the basis for certain search decisions. The Congressman also questioned whether the incident, in which the patient died, raised issues of neglect and mismanagement, and whether it was appropriate for an administrative Board to conduct the investigation.
Background
The patient, referred to in this report as Mr. B, was a 67-year-old male with prior multiple admissions to the Lyons Campus for ·(b)(3)(b)(6)·· · · · · · · · ··· · · · · · · · · · · · · · · · · · · · · · · ·. Mr. B was ·(b)(3)·(b)(6) · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · May 14, 1998, after ·(b)(3)·(b)(6) · · · · · · ·· ·· ·· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·· · · · · · · · · · ·. Beginning May 18, 1998, Mr. B was authorized to leave the ward by himself for 2 hours in the morning. On Saturday, May 30, Mr. B did not return to his ward and was reported missing that evening. Lyons Campus officials began an extended search for Mr. B, but terminated it before he was found. On the morning of Monday, June 1, 1998, Mr. B was found unresponsive, lying in a construction trench near an administrative building in an area of the Campus known as Circle I. (The Lyons Campus has multiple buildings, organized into two groups, Circle I and Circle II. Maps of the facility are provided in Appendix A.) A VA medical emergency team responded to the situation, as well as the Campus fire department personnel, three police officers, and several bystanders.

The VA OIG concluded:

Recommendation 2
The Director, VISN 3, should:
a) Take appropriate administrative action against Mr. Kenneth Mizrach for failing to ensure that the Lyons Campus had a sufficiently detailed plan to search the facility for missing patients, including a minimum time frame before calling off an unsuccessful extended search for an incapacitated patient; and
b) Review Mr. Mizrach’s actions with respect to maintaining a local policy to initiate extended searches prior to approval by executive management. Also, review

Mr. Mizrach’s actions with respect to the policy amendment that Ms. Piche initiated.

Ensure that Mr. Mizrach complies with VHA policy unless, and until, it is changed…

 

http://www.youtube.com/watch?v=WJkvsfmdyAI

http://www.youtube.com/watch?v=c1dr9az2UPo

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