Veterans Die While Waiting for Appointments, Operating Rooms Infested with Flies and the Return of a Fired VA Director: 2017 #VAFails in Review
If you were shocked by the first part of this series, hold on tight. #VAFails during the summer of 2017 range from patient deaths to cockroach-infested food.
There were a few bright spots for the Department of Veterans Affairs in bringing more accountability to the department. In late April, the president signed an executive order creating the Office of Accountability and Whistleblower Protection. This office was meant to focus more attention on misconduct and mismanagement at the VA and protect whistleblowers who bring misconduct forward.
For that office to be effective, Congress had to pass legislation giving it some teeth. In June the president signed the much-anticipated VA Accountability and Whistleblower Protection Act of 2017.
This bipartisan bill increased the VA’s authority to fire poorly-performing employees and those found to be participating in misconduct. It was an important move towards accountability and transparency at the VA.
Secretary Shulkin’s VA began publishing a regular accountability report to create transparency in employment issues. Since January 2017, the VA has been able to remove, demote or suspend more than 1,800 employees.
But, as we’ll see, a culture of accountability hasn’t taken full effect at the VA yet.
The Office of Inspector General released a report that one hundred veterans died while waiting for appointments at the Los Angeles VA. Even worse, those deaths occurred within just one year. Veterans dying while waiting for appointments isn’t new. During the Phoenix VA scandal, which sparked more nationwide attention on the VA, 40 veterans died while waiting for care on secret wait lists.
On the other side of the country in Boston, veterans with traumatic brain injuries were misdiagnosed or not informed of their conditions. A 2012 report found that the Boston VA failed to inform some patients of positive TBI screenings or refer patients for comprehensive evaluations.
After claiming to fix that problem, an inspection found that hospital staff had improperly assessed the degree of disability in one out of six TBI claims. The report also found vets weren’t receiving proper information about their diagnoses or were being assessed by doctors not trained in TBI treatment.
Just outside Chicago, the Hines VA was accused of serving patients raw and expired food. The Hines VA also had a cockroach infestation in the kitchen. The OIG confirmed that not only did cockroaches make their way into veterans’ food, but that leadership knew about the problem.
The Government Accountability Office found that the VA’s record keeping may not be accurate and thus may not “accurately reflect productivity and efficiency.” Patient scheduling is negatively impacted if timekeeping and workload data are inaccurate. Failure to follow VA policy and procedure lengthens wait times for veterans.
In Florida, the OIG found the VA had improperly paid out $17 million in claims between 2012 and 2016. That’s overpayment in one out of every three claims handled by the Florida VA processing center.
In Michigan, the IG found a patient received a blood transfusion despite notes in his chart indicating conditions that should have prevented a transfusion. Worse, the caregiver and supervisor neglected to report the veteran’s adverse reaction to the transfusion.
“Third world conditions” isn’t a descriptor you’d expect to read in a report on the Manchester VA, or any VA for that matter. Nevertheless, that’s how one whistleblower described conditions at the only VA facility in New Hampshire. Whistleblowers made allegations of dirty surgical tools, an operating room infested with flies for years and improper spinal care. The Office of Special Counsel said there was a “substantial likelihood” of legal violations, gross mismanagement, abuse of authority and danger to public health.
These reports are troubling given the facility has a four-out-of-five-star rating from the VA.
The Merit Systems Protection Board blocked the firing of DC VA Medical Center Director Brian Hawkins, despite the OIG’s report of dangerous conditions under his watch. He was reassigned to a different position within the VA.
In Buffalo, five hundred veterans were informed they may be at risk of infection due to staff’s failure to follow cleaning instructions on medical equipment.
It seems like this must be the worst of it in 2017, right? The VA can’t fail worse than vermin infestations, misdiagnoses and wastes of millions of dollars, can it? Stay tuned for the third and final installment of the 2017 #VAFails in review to find out.