Veterans Affairs Department officials acknowledged "unsafe clinical practices" in its initial review of patient care practices at its medical center in Tomah, Wis., a facility nicknamed "Candy Land" for the alleged overprescription of pain medications by officials there.
In a report released Tuesday, VA Acting Under Secretary for Health Carolyn Clancy said investigators found multiple instances of patient harm "at least partially attributable to prescribing practices" of officials at the facility.
"The team also found that Tomah patients were 2.5 times more likely than the national average to be prescribed (heavy doses of) opioids," the report said. "The team also found that an apparent culture of fear at the facility compromised patient care and impacted staff satisfaction and morale."
The report was released on the same day that VA Deputy Secretary Sloan Gibson visited the facility to meet with employees and patients' families to discuss rumors and problems. It also came one day after lawmakers announced plans to hold a field hearing at the controversial site at the end of the month.
Also on Monday, partly as a response to the ongoing Tomah problems, VA officials announced the rollout of a new administrative tool to ensure medications are not over-prescribed to patients.
More than 2,000 primary care providers in VA clinics throughout the country have access to that information now, designed to cut down on adverse drug interactions and prescription misuse.
Tuesday's report did not recommend any disciplinary actions against Tomah staff. Instead, investigators recommended only that officials "consider a more in-depth evaluation of the clinical and administrative practices" at the facility.
Clancy said that additional review is already underway.
Another administrative review by VA's Office of Accountability Review has already begun, looking into allegations of retaliation against whistleblowers who spoke out about the pain medicine abuse.
VA officials said investigators from the department's Office of the Inspector General and the Department of Justice's Drug Enforcement Administration also have opened cases related to the accusations of misconduct and potential malpractice.
Problems at the facility came to light last year following a Center for Investigative Reporting investigation, which found that prescription and use of opiates at the Tomah medical center rose sharply in recent years, even as the number of patients fell.
Members of the Wisconsin congressional delegation have demanded a formal VA investigation, but also have taken criticism for not reacting sooner to allegations of prescription abuse.