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Audit blames mismanagement for 3 deaths on Atlanta VA's watch

ATLANTA -- Three deaths occurred over the past two years under the watch of the Atlanta VA Medical Center after it lost track of mental health patients it referred to a contractor while also not keeping a close enough eye on those under its own care, a new federal audit found.

Many of the 4,000 patients the veterans hospital referred to the DeKalb Community Service Board “fell through the cracks,” the audit by the Department of Veterans Affairs’ Inspector General found. One died of an apparent drug overdose after the community service board was unable to connect him with a psychiatrist for nearly a year after his referral. Another tried to see the VA facility’s Health Care for Homeless Veterans psychiatrist, who was unavailable, and the staff told the man to take public transportation to the emergency department. He never went and committed suicide the next day.

The mental health ward at the hospital was the scene of yet more mismanagement, the audit found. Staff members for two hours one afternoon lost track of a suicidal patient who was supposed to be closely monitored, and he died that night of an overdose of drugs he got from a fellow patient.

In a separate case, a patient with a history of substance abuse and domestic violence wandered the building for four hours unsupervised, during which time he injected himself with testosterone. Another patient who had been diagnosed with schizophrenia was missing for eight hours and told nurses he “got lost” on the way back to his room.

The audit consisted of two reports, one for the in-patient program and one for the outpatient program.

Atlanta VA officials did not dispute any of the audit’s findings and are implementing its recommendations, from new policies on contraband and drug screenings to a new patient tracking system.

“We want to express our heartfelt condolences to the families and friends of the three veterans cited in the reports who died,” Dr. David Bower, the hospital’s chief of staff, said in a statement. “All suicides are tragic events and VA, including this VA, has placed a huge emphasis on suicide prevention. One suicide is one too many. Providing the best health care possible to our nation’s heroes is our goal and we are committed to it.”

Michael Zacchea, a Marine veteran on the board of directors for the advocacy group Veterans for Common Sense, questioned why the hospital would only now be systematically tracking its patients.

“It’s inexcusable,” he said. “I don’t think it’s an indication that they are finally getting it. I think it’s the opposite.”

The 26-acre, 405-bed medical center, located in Decatur, works in conjunction with eight outpatient centers in the Atlanta region. It serves 86,000 patients.

Acting on an anonymous tip, the inspector general started its investigation last year. The pair of reports released Wednesday were a striking condemnation of hospital policies due to mismanagement and a lack of staffing.

From 2011 to 2012, the audit found, the wait list for mental health treatment skyrocketed from 53 to 397 patients and there were 66 vacant full-time staff positions. A VA report found that a lack of space and low pay for psychiatrists were the primary causes of the vacancies.

Thomas Bandzul, legislative counsel for Veterans and Military Families for Progress, said Atlanta’s VA is one of the most overworked systems in the country.

“They’re just overwhelmed,” Bandzul said. “The system is not designed to handle the numbers that they have in the region.”

Bower, the hospital’s chief of staff, stopped short of asking for more funding.

“The Atlanta VA Medical Center is one of the fastest-growing facilities across the VA, with over 1 million outpatient visits last year,” he said. “We are confident that we have the necessary resources to provide all our veterans the care they deserve and earned.”

Advocates said the Atlanta VA’s struggles can be found throughout the country, as veteran suicides and mental illness remain a rampant problem.

U.S. Rep. Sanford Bishop, an Albany Democrat, called the inspector general’s report “disgusting” but said the vast majority of VA patients do not have such complaints. Bishop is the top Democrat on the U.S. House Appropriations subcommittee that oversees VA funding.

“I don’t think that there’s anyone who can say that the VA has been underfunded since 2007,” Bishop said. “Money is not the issue here. It is management, oversight and accountability, and we are going to do our best to make sure that those measures are taken, that these kinds of incidents will not be recurring.”

From 2003 to 2012 the total VA budget rose from $59.6 billion to $125.3 billion, according to the Congressional Research Service, as the VA has treated 900,000 veterans returning from Iraq and Afghanistan. More than half were diagnosed with mental disorders.

President Barack Obama signed an executive order last year directing federal agencies to dramatically expand suicide prevention and mental health care. Still, Bandzul said more must be done.

“They need more money,” he said. “They need about 25 percent more just in mental health alone. … The mental health field in general is just way, way, way overtaxed in terms of the number of people they have vs. the need. It’s a scary algorithm. And the ones who pay the price, obviously, are the veterans.”

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