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#VAFail: Pattern of abuse of Montana veterans shows VA reform long overdue

By Concerned Veterans for America

On a per capita basis, Montana has the third-largest veteran population of any U.S. state. At least 10% of residents, about 90,000 people, served in the military. In a state as vast as Big Sky Country, quality care is not always easily accessible, especially for those stuck using only the VA. Montana veterans need health care choice.  

A January 2023 report from U.S. Department of Veterans Affairs (VA) inspector general found the care Montana veterans are getting at VA facilities is not even substandard.  

It is close to criminal.  


Montana veterans subject to “long history of patient mistreatment”  

The inspector general began looking into the state’s VA health system after an abuse allegation regarding a patient in his late 70s at the Miles City VA Community Living Center (CLC). VA Police also were notified about the allegations. 

The inspector general examined that patient’s quality of care during hospitalizations immediately before and after the CLC admission, and also reviewed CLC facility leaders’ oversight and actions related to the allegation. 

As the Billings Gazette explains, the inspector general “found a long history of patient mistreatment and allegations of abuse by staff” at the Miles City facility. The newspaper notes the inspector general’s 47-page report used the term “mistreatment” at least 97 times. 

The VA was aware of the abuse. In fact:   

  • A 2018 factfinding examination “substantiated allegations of mistreatment” by Miles City CLC nursing staff. 
  • An August 2020 administrative investigation found two CLC nurses were witnessed or observed “to be exhibiting behaviors consistent with patient abuse and neglect.” 
  • A November 2020 administrative investigation found the behavior of one CLC nurse met criteria for “serious offenses of patient mistreatment”. 


Why VA reform? “Lack of care coordination” meant missed cancer diagnosis 

In 2021, mistreatment was still happening. 

As the inspector general explains, the patient in his 70s was admitted to the Miles City facility “for shortness of breath and an inability to perform self-care.” After a 34-day stay and treatment for COVID-19 pneumonia, the patient was admitted to the CLC for rehab. 

Over the next few weeks, the patient was bounced back and forth from the CLC to state veterans homes. Caregivers complained the veteran was not participating in rehab.  

Finally, the veteran was admitted to the intensive care unit of a community hospital. 

It was the caregivers at that facility who discovered a mass in the lung that appeared to be stage-four metastatic cancer. 

The veteran died nine days later.  

As the Billings Gazette notes, the VA admitted “the lack of care coordination” at VA facilities “did not afford the patient, or the patient’s family, the opportunity to determine the most appropriate care plan.”  


Miles City VA allowed nurses to continue working with Montana veterans 

Instead of determining why the patient was reluctant to take part in rehab, the inspector general says that, on at least two separate occasions, “the patient was forced to participate in physical therapy in the CLC by a physical therapist and nursing staff.”  

The force resulted in bruising and skin tears that required first aid.  

Under VA rules, patients “have the right to accept or refuse any medical treatment or procedure.” The handbook also states, “providers are not permitted to ‘unduly pressure or coerce the patient into consenting to a particular treatment or procedure.’” 

The individuals overseeing the nurses and physical therapists seemed unfazed by the veteran’s injuries. They did not report the cuts or bruises even though, under VA rules, nurse managers and physicians have “a duty to report patient safety incidents.”  

But that’s not all the inspector general found.  

Incredibly, two “nurses involved in the mistreatment with this patient were also involved in the other incidents, one in the 2018 incident and both in the August 2020 incident.”  

Montana veterans — all veterans — deserve better. It is time for VA reform.  


Health care choice will free Montana veterans 

It is possible this patient never should have been transferred to the Miles City CLC. Not just because of the CLC’s prior record of mistreatment, but because, according to the inspector general, “the CLC did not have a designated screening process for reviewing the suitability of patients for admission, potentially limiting the abilities of the CLC to determine … the correct level of care.”  

In April 2022, a year after the patient died, the Miles City CLC was shut down. It was allowed to reopen just five months later.  

According to the Miles City Star, Montana’s VA system covers 147,000 square miles. There are 18 care sites, or one for every 8,166 square miles.  

The system is too vast, and too riddled with problems, for Montana veterans to be able to count on quality care through VA alone.  

VA reform is necessary. It is time for policymakers to support legislation to give veterans full choice through a portable health care benefit that includes flexibility to choose the health care that meets their unique needs. 

Read more about how health care choice could prevent stories like this one from ever happening again.