8 years for psych eval a 'harmless error,' VA says
By TRAVIS J. TRITTEN | STARS AND STRIPES Published: June 23, 2014
WASHINGTON — A veteran admitted to a long-term VA mental health care facility in Massachusetts waited eight years for his first comprehensive psychiatric evaluation by staff.
Another patient with a 100 percent service-connected psychiatric condition was committed at the same Brockton facility for seven years before a single psychiatric note was placed on his medical chart.
The cases are among dozens of incidents whistleblowers in the Department of Veterans Affairs have reported out of concern for patients’ safety but the VA has failed to take the incidents seriously, or admit they might affect the quality of treatment in its nationwide system of hospitals and clinics, according to a letter sent to President Barack Obama on Monday by the U.S. Office of Special Counsel.
The VA has instead claimed such incidents were “harmless errors,” according to the OSC, an independent federal watchdog charged with protecting whistleblowers and fielding complaints.
“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,” according to the letter by Carolyn Lerner, head of the OSC. “As a result, veterans’ health and safety has been unnecessarily put at risk.”
The OSC letter, which was also sent to Congress, comes after revelations that the VA systematically falsified patient wait lists to mask long waits. About 57,000 veterans nationwide have waited over a month to receive health care guaranteed as part of their military service, and whistleblowers have claimed delays have led to deaths.
A VA inspector general investigation found the wait list were improperly manipulated at 70 percent of hospitals and clinics nationwide.
The OSC letter implicates the VA’s Office of the Medical Inspector, which oversees quality of care, in the widening scandal over dysfunction in the department.
In response to whistleblower claims about the Brockton mental health patients, the OMI said it “feels that in some areas [the veterans’] care could have been better but OMI does not feel that their patient’s rights were violated,” Lerner wrote in the letter.
The OSC now has 50 pending VA whistleblower cases alleging threats to patient health or safety and 29 have already been referred to the VA for investigation. The department has been generating an outsized number of complaints to OSC — over 25 percent of all cases coming from the federal government, Lerner noted.
Typically, the OSC will take whistleblower complaints and send the allegations to VA for investigation. Depending on the outcome, the department can choose to fix problems or decide no action is needed.
Lerner said the VA has substantiated whistleblower claims in case after case but then decided there was no wrongdoing or threat to veterans:
- In Little Rock, Ark., a whistleblower reported that hospital suction equipment was not available when needed and a veteran being treated at the time later died. The VA’s medical inspector, which oversees quality of care, found there was not enough evidence that the lack of equipment caused the death and concluded the quality of the health care met standards.
- An employee at a VA hospital in Fort Collins, Colo., reported severe scheduling and patient wait-time problems there. The facility “blind scheduled” veteran patients without consulting them and nearly 3,000 who had to cancel were unable to reschedule.
“One nurse practitioner alone had a total of 975 patients who were unable to reschedule appointments,” Lerner wrote.
The VA medical inspector reported that “due to the lack of specific cases for evaluation, OMI could not substantiate that the failure to properly train staff resulted in a danger to public health and safety.”
Watching the detectives
The Office of Special Counsel told the president that the VA should appoint an individual to look into whether there are systemic problems in how whistleblower complaints have been handled by OMI.
On Monday, the VA’s newly appointed Acting Director Sloan Gibson lauded the courage and integrity of whistleblowers and said he has accepted the OSC recommendation. A review of the VA medical inspector will be completed in two weeks, he said.
“I am deeply disappointed not only in the substantiation of allegations raised by whistleblowers, but also in the failures within VA to take whistleblower complaints seriously,” Gibson said in a released statement.
Rep. Jeff Miller, R-Fla., who chairs the House Veterans Affairs Committee, said the OMI decisions do not make sense after dozens of veteran deaths around the country have been linked to delays and other lapses in care.
“[I]n the fantasy land inhabited by VA’s Office of the Medical Inspector, serious patient safety issues apparently have no impact on patient safety,” Miller said in a released statement. “It’s impossible to solve problems by whitewashing them or denying they exist.”
The VA medical inspector owes an explanation to the country of why it keeps reaching “implausible” conclusions regarding incidents that appear to threaten patient safety and care, he said.
Sen. Claire McCaskill, D-Mo., called late last week for more information from OSC on recent reports of VA retaliation against whistleblowers. On Monday, she called the OSC letter “disturbing” and that anybody involved in a cover-up over threats to patient safety at the VA should be fired.
“I’m outraged, not only by what these whistleblowers found, but by indications that those findings were ignored or minimized by VA management, perpetuating systemic problems while veterans suffered,” McCaskill said in a written statement.