Troubles at VA Medical Center
Three recent reports have cited problems at the 405-bed facility in Decatur
— Two audits by the Inspector General of the U.S. Department of Veterans Affairs linked the deaths of three veterans over two years to mismanagement in the mental health unit. Among its findings: the wait list for mental health treatment skyrocketed from 53 to 397 patients from 2011 to 2012; and many of the 4,000 patients referred to outside mental health facilities were not properly tracked and “fell through the cracks.”
— In the third report, inspectors from The Joint Commission, which accredits health care facilities, found instances of missing medications, improperly stored or cleared equipment, imcomplete patient treatment plans, and lack of process for determining if doctors are competent to do certain procedures. The report also cited numerous physical facility issues.
Atlanta VA Medical Center officials are taking action to correct mismanagement in the facility’s mental health unit, but more needs to be done, members of a congressional delegation said Monday after visiting the Decatur hospital.
“If I think somebody needs to be fired, I will not rest until they’re gone,” U.S. Rep. Jeff Miller, R-Fla., and chairman of the House Committee of Veterans’ Affairs, said after meeting with hospital officials.
He was joined by four Georgia congressmen, including Atlanta Democrat David Scott, who called for continued investigation into problems at the 405-bed center — including reevaluating top management.
“We are determined to get to the bottom of it,” Scott said. “There is no escaping the situation that this has been a colossal failure of the management of this hospital.”
The congressional visit followed two recent audits by the Inspector General of the U.S. Department of Veterans Affairs that linked the deaths of three veterans to the hospital’s failure to keep track of them.
More than 4,000 veterans the hospital referred to outside mental health facilities “fell through the cracks,” the reports showed.
One died of an apparent drug overdose after providers failed to connect him with a psychiatrist. Hospital staff told another man who tried to see a VA psychiatrist, who was unavailable, to take public transportation to the emergency department, but he never went and committed suicide the next day.
Miller said the hospital has changed how it contracts work to outside providers, but that more fixes are needed. He also said his committee will continue to investigate and that robust oversight from both House and Senate lawmakers is needed.
The other Georgia congressmen on Monday’s visit were Republicans Phil Gingrey and Paul Broun, along with Democrat John Barrow.
Other instances cited in the mental health unit audits included the case of a suicidal patient who died of an overdose of drugs given to him by another patient.
In another case, a patient with a history of substance abuse wandered the building unsupervised and injected himself with testosterone. A patient with schizophrenia who was missing for eight hours told nurses he “got lost” on the way to his room.
The Department of Veterans Affairs said in a statement that it agrees with recommendations made by the audits and is taking aggressive action to address each finding. It also stated the Atlanta veterans hospital will continue to closely monitor mental health care and manage contracts with outside mental health providers.
The 26-acre medical center works in conjunction with eight outpatient centers in the Atlanta region and serves 86,000 patients.
The VA has deferred bonuses for some senior executives in its Southeast and Pennsylvania medical networks pending further review. The Atlanta veterans hospital is one of those under review.
Separately, a confidential inspection report obtained last week by Channel 2 Action News revealed numerous problems in other areas of the hospital — including missing medications, fire safety concerns, improperly cleaned medical equipment and a doctor performing a procedure he wasn’t authorized to do.
The hospital has 45 to 60 days to fix the problems or risks losing its accreditation through The Joint Commission, a nonprofit organization that sets safety and quality standards for more than 20,000 health care facilities and programs across the nation.
“(The) VA recognizes the importance of instituting a national policy at all VA medical centers addressing hazardous items, visitation, urine drug screens and escort services for inpatient mental health programs,” according to a statement from the VA.
Miller said he was surprised that a health care network as large as the VA doesn’t have standard procedures, especially in mental health care. He added that a tremendous number of veterans are coming home and many of them have mental health issues.
“This is not just here in Atlanta,” Miller said. “This is all across this country.”
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