Veterans Affairs acting Secretary Sloan Gibson testifies July 16 on Capitol Hill in Washington, before the Senate Veterans' Affairs Committee hearing on the state of VA health care in the wake of revelations of neglect and delayed medical visits. He is accompanied by Assistant Deputy Undersecretary For Health For Administrative Operations Philip Matkowsky. (Photo: J. Scott Applewhite/AP)
WASHINGTON — In 2003, a veteran who had served in the Vietnam War entered a Veterans Affairs live-in treatment facility after trying several times to kill himself — including by stabbing himself in the stomach.
In 2008, he briefly saw an emergency room psychiatrist because of his "crying and disruptive behavior," but according to VA records, that was the only time he saw a psychiatrist from the day he entered the facility until 2011, according to a report from January.
Newly released documents detail this case out of Brockton, Mass., as well as other startling findings by VA's Office of the Medical Inspector that had been hinted at in an Office of the Special Counsel Report last month. The documents came to light after Rep. Jeff Miller, R-Fla., chairman of the House Veterans' Affairs Committee, wrote to VA acting Secretary Sloan Gibson and requested them.
"In reality, the deaths of dozens of veterans across the country have been linked to delays in VA care and other serious department health care problems," Miller told USA Today, "but in the fantasy land inhabited by VA's Office of the Medical Inspector, serious patient-safety issues apparently have no impact on patient safety."
Although the Office of the Medical Inspector found that, in the Vietnam veteran's case, "It did not appear that the psychiatry service makes routine or consistent attempts to follow residents after an initial consultation or to assess response to recommendations," there were no repercussions. Instead, it recommended seeing patients at least annually.
A second Brockton patient — a Green Beret with Parkinson's disease and 100 percent disabled by post-traumatic stress disorder — was admitted in 2005 with confusion, depression, dementia, psychosis, hallucinations and suicidal ideation, as well as Parkinson's disease. He was not seen by a psychologist until 2012. The Office of the Medical Inspector concluded that "more frequent assessment by psychiatry service would have been beneficial."
Despite these findings, the VA's medical inspector "failed to acknowledge that the confirmed neglect of residents at the facility had any impact on patient care," Carolyn Lerner, who leads the Office of the Special Counsel, wrote in a letter to President Obama.
She wrote that VA's "harmless error" defense prevents the VA from "acknowledging the severity of systemic problems."
Gibson responded to Lerner's letter by saying the VA needs to take whistle-blower complaints seriously. On Thursday, Gibson will testify at a House Veterans' Affairs Committee about steps the VA has taken to address problems the department faces, including long wait times, manipulation of data and accountability.
"VA owes it to America's veterans and American taxpayers to explain the steps it is taking to hold those responsible for these reprehensible lapses in care accountable," Miller said.
In another case, a former nursing assistant charged in 2012 that staff often did not help elderly veterans at a community living center in San Juan, Puerto Rico, with bathing, using the bathroom, eating or drinking.
"The whistle-blower presented as an exampled that nursing staff failed to bathe immobile residents who had urinated or defecated in their beds upon being called by the residents," the report states. Family members and residents also complained, and the inspectors noted a "strong fecal odor" during their tour.
In that case, officials found that the faulty care violated abuse and neglect laws and recommended that a board evaluate the center's leadership, and they suggested that the staff be "re-educated."
The same whistle-blower alleged that patients at that facility had been left on the floor after falling out of their beds. He said he was told not to report the falls because "it required too much paperwork." The investigators found the fall rate was higher than at other facilities, so they could not substantiate the claim that not all falls were recorded.