By Richard Simon, Los Angeles Times
WASHINGTON — In another damning report on the Department of Veterans Affairs, the U.S. Office of Special Counsel on Monday assailed the VA for what investigators said was its unwillingness to acknowledge the “severity of systemic problems” that have put patients at risk.
The special counsel, Carolyn N. Lerner, reported in a letter to President Barack Obama that investigators found a “troubling pattern of deficient patient care,” and expressed concern about what she termed the department’s unwillingness to acknowledge the impact of its problems on patient safety. Her office is now investigating more than 50 cases brought by whistle-blowers.
“The VA, and particularly the VA’s Office of the Medical Inspector, has consistently used a ‘harmless error’ defense, where the department acknowledges problems but claims patient care is unaffected,” she wrote. “This approach has prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans.
“As a result, veterans’ health and safety has been unnecessarily put at risk,” she said.
The Jackson, Mississippi, VA medical center operated “ghost clinics” where veterans were scheduled for appointments with no assigned provider, resulting in veterans leaving without treatment, she said, and nurse practitioners at the same facility improperly prescribed narcotics to veterans in violation of federal law, among other problems.
In Buffalo, New York, health care professionals do not always comply with VA sterilization standards, the report said, and in Little Rock, Arkansas, suction equipment was unavailable when it was needed to treat a veteran who later died. In Grand Junction, Colorado, the drinking water had elevated levels of Legionella bacteria and standard maintenance procedures to prevent bacterial growth were not performed, Lerner wrote.
In Brockton, Massachusetts, a veteran who was in a mental health facility from 2005 through 2013 had only one note written in his medical chart; the note, written in 2012, addressed treatment recommendations, according to Lerner. Another veteran who was admitted to the facility in 2003 did not receive his first comprehensive psychiatric evaluation until 2011, she said.
The VA Office of the Medical Inspector “failed to acknowledge that that the confirmed neglect of residents at the facility had any impact on patient care,” she said.
U.S. Representative Jeff Miller (R-FL), chairman of the House Veterans’ Affairs Committee, said the letter highlights the VA’s attempts to “downplay the impact serious deficiencies in VA health care have had on patients.”
“In the fantasy land inhabited by VA’s Office of the Medical Inspector, serious patient safety issues apparently have no impact on patient safety,” he said in a statement. “It’s impossible to solve problems by whitewashing them or denying they exist.”
Acting Secretary of Veterans Affairs Sloan Gibson said in a statement Monday that he was disappointed in the “failures within VA to take whistle-blower complaints seriously” and that he has directed a review of the operation of the Office of the Medical Inspector, to be completed within 14 days.
The special counsel’s letter comes after the VA’s own reports have found systemic problems in scheduling of patients in a timely manner, including instances of staff falsifying records to cover up long waits.
Lerner said her office also had found the use of a “bad boy” list at the VA facility in Fort Collins, Colorado, for staff who scheduled appointments for greater than 14 days than the veteran’s desired date for an appointment. Staff members were instructed to alter wait times to make the waiting periods look shorter, the special counsel said.
The office also is investigating allegations that two schedulers were reassigned from Fort Collins to Cheyenne, Wyoming, for not complying with instructions to “zero out” wait times. After the employees were transferred, officially recorded wait times for appointments drastically improved, according to the special counsel, “even though the wait times were actually much longer.”
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