The Atlanta Journal-Constitution and Channel 2 Action News were the first to report that federal audits found that mismanagement at the Atlanta VA Medical Center’s mental health unit contributed to three deaths. The AJC continues to follow developments as the VA hospital comes under scrutiny, including today’s report on changes underway at the facility.
Revelations of pervasive mismanagement at the Atlanta VA Medical Center that contributed to the deaths of three veterans have not led to anyone being fired, despite outcries from top U.S. lawmakers.
The hospital’s new director, Leslie Wiggins, said Thursday that a review of the facility’s troubled mental health unit has resulted in the hiring of 17 additional mental health providers and a new patient tracking system. A new outpatient clinic with mental health services is also set to open in Oakwood this September, among other changes.
Wiggins, who took the reins of the Decatur-based facility on May 20, declined to discuss any specific disciplinary actions of hospital staff.
“I cannot say that I think anyone should be fired,” she said at a news conference. “The employees … regret the loss of any veteran. The organization is taking the whole matter very seriously.”
The changes come in the aftermath of two April audits by federal inspectors that linked the deaths of three veterans to inadequate oversight by hospital staff. The death of a fourth veteran, who committed suicide in a hospital bathroom, later came to light.
At least two employees have received reprimands and another two were recommended for reprimands in the wake of the findings. A reprimand can appear in an employee's file for up to three years, but it can be destroyed after six months depending on the worker's behavior.
Federal lawmakers say that’s not enough and are calling for more severe punishments.
“It’s a miscarriage of justice that nobody’s been fired,” said U.S. Rep. David Scott, an Atlanta Democrat, in an interview with The Atlanta Journal-Constitution. “Somebody’s head has got to roll there.”
Scott said he told Wiggins weeks ago that employees must be fired and that she had agreed. But he questioned whether she has been given that authority or has been set up for failure by those above her.
The scathing audits revealed that many of the 4,000 veterans the hospital referred to outside mental health facilities “fell through the cracks.”
In one case, a man who tried to see a VA psychiatrist who was unavailable was told by hospital workers to take public transportation to an emergency room. He never did and committed suicide the next day. Another man died of an apparent drug overdose after providers failed to connect him with a psychiatrist. And third patient died of an overdose of drugs given to him by another patient.
The hospital’s new database system will help keep track of every veteran who is referred to an outside mental health provider, Wiggins said. VA licensed clinical social workers will also be stationed at facilities the hospital contracts with to help coordinate care, she said.
Wiggins said the hospital has also successfully reduced wait times for mental health services in recent months, with 91 percent of veterans receiving a new appointment within 14 days. The hospital is also planning to expand outpatient mental health services at its new Fort McPherson facility, which will also have 40 patient beds.
“I will continue to assess programs and processes,” she said. “Veterans can be assured of our commitment to deliver high-quality care.”
The hospital is also working to address dozens of safety problems, including fire hazards and unsecured prescription narcotics, detailed in a separate report from the Joint Commission, a national organization that accredits hospitals.
The patient deaths and other safety issues have cast a dark shadow over the Atlanta hospital, U.S. Rep. Jeff Miller, R-Fla., said in a recent statement.
“Now is not the time for bureaucratic slaps on the wrist,” he said.
Miller, who heads the House Committee on Veterans’ Affairs, toured the hospital in May along with Scott and three other Georgia congressmen. The 405-bed hospital serves roughly 90,000 veterans and is the largest such facility in the Southeast.
Lawmakers say failures at the Atlanta VA represent much larger problems with the Department of Veterans Affairs nationwide that leaders in Washington need to address.
“The complacency and deceitfulness of VA leadership at both local and central office levels cannot be tolerated when the health and safety of our veterans and their families are at stake,” Miller wrote in a letter to the White House in May.
Four veterans have died and VA Secretary Gen. Eric Shinseki “has yet to set foot” in the Atlanta hospital, Scott said.
“We can’t let this rest,” he said. “There’s a problem at the VA, and it’s at the top.”
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