Inspectors find problems at Decatur VA hospital

Troubles at Atlanta VA Medical Center

Inspectors from The Joint Commission, which accredits health care facilities, found numerous problems at the Atlanta VA Medical Center during a visit there in March. Those issues include the following:

  • Missing medications
  • Medical equipment not cleaned and stored properly
  • Vague and incomplete treatment plans for patients
  • Pharmacy storage areas covered in dust
  • Natural gas spigots at the dental clinic not labeled correctly
  • Doors not latching correctly
  • No process for assessing whether doctors are competent to perform certain procedures
  • Equipments and carts in the hallway restricting access to rooms
  • Wires strapped to sprinkler piping
  • Lacking process for disposal of hazardous medications
  • Patient at risk for falls did not have a bracelet to alert staff of that risk

Mental health mismanagement

Two recent audits by the Inspector General of the U.S. Department of Veterans Affairs linked the deaths of three veterans over two years to rampant mismanagement of the mental health unit at the Atlanta VA Medical Center in Decatur.

Among the findings:

  • From 2011 to 2012, the wait list for mental health treatment skyrocketed from 53 to 397 patients.
  • Many of the 4,000 patients referred to outside mental health facilities "fell through the cracks."
  • Hospital staff lost track of a suicidal patient who was supposed to be closely monitored for two hours one afternoon. He died that night of an overdose of drugs he got from another patient.
  • A schizophrenic man was missing for eight hours and told nurses "he got lost" on the way back to his room.
  • Another patient with a history of substance abuse wandered the building for four hours, during which time he injected himself with testosterone.
  • A patient who was referred to an outside facility died of an apparent drug overdose after the facility was unable to connect him with a psychiatrist for nearly a year after his referral.
  • Another man was told by hospital staff to take public transportation to the emergency room after a VA psychiatrist was not available to see him. He never went and committed suicide the next day.

Missing medications, improperly cleaned medical equipment and a doctor performing a procedure he didn’t have permission to do are among numerous problems recently discovered at the Atlanta VA Medical Center in Decatur.

Inspectors from a national group that accredits health care facilities noted dozens of instances of nurses, doctors and other hospital staff failing to follow proper procedure during a four-day visit to the veterans hospital in March. The problems are detailed in a confidential report obtained by Channel 2 Action News.

Among them, inspectors found wires not properly sealed with fire-resistant material, doors that didn’t latch properly and other fire safety concerns, which hospital staff said they repaired shortly after they were pointed out.

The report also noted vague and incomplete treatment plans for patients, including failing to address safety issues for a mentally ill man who came into the 405-bed hospital in hand cuffs, was placed in restraints and “clearly was out of control and a danger to staff.”

The report comes on the heels of two recent audits by the Inspector General for the U.S. Department of Veterans Affairs that linked the deaths of three veterans to widespread mismanagement of the Decatur hospital’s mental health unit.

Many of the 4,000 patients the veterans hospital referred to outside mental health facilities “fell through the cracks,” including one man who died of an apparent drug overdose after providers failed to connect him with a psychiatrist, the audits found. In another instance, hospital staff lost track of a suicidal patient who died that night of an overdose of drugs given to him by another patient.

A hospital spokesman did not comment directly on the latest report.

“We continue to provide our veterans with the high quality health care that they’ve earned and deserve,” said the spokesman, Gregory Kendall.

The VA should investigate the entire Atlanta facility and replace anyone who was derelict in their duties, said U.S. Rep. David Scott, an Atlanta Democrat.

“We need to get staff in this facility who care about our veterans,” Scott said. “This is shameful, disgraceful, and our veterans deserve better.”

U.S. Rep. Jeff Miller, R-Fla., who chairs the House Committee on Veterans’ Affairs, has called for hospital executives to be disciplined. Records recently obtained by The Atlanta Journal-Constitution and Channel 2 Action News revealed that former hospital director James A. Clark received $65,000 in performance bonuses over a four-year span. He left in December.

Miller, Scott and other lawmakers are set to tour the troubled facility on Monday.

The hospital will have 45 to 60 days to fix problems cited in the most recent report by The Joint Commission, an independent nonprofit that sets quality and safety standards for more than 20,000 health care organizations and programs across the country. In 2011, the commission named the veterans hospital as one of its top performers in key quality measures, including heart failure and pneumonia.

A spokeswoman for the commission said it does not release or comment on hospital survey results. Failing to correct problems within the deadline can threaten a hospital’s accreditation.

The commission’s findings include numerous situations where medications were missing or were left unsecured out in the open. In one instance, two paper bags with medications, including a filled prescription for morphine, were left unattended on a case worker’s desk.

The report’s findings include improper storage of medical equipment, including parts of a device used to look at a patient’s voice box that were left in an open plastic bag that had been used multiple times.

Inspectors also reported an incident of an emergency department doctor placing a tube into the windpipe of a patient who was having trouble breathing even though he had not been granted privileges to perform that type of procedure.

Marine veteran Michael Zacchea, who is on the board of the advocacy group Veterans for Common Sense, said he believes the troubles in Atlanta reflect a much larger, endemic problem with the VA system as a whole. Numerous reports of doctors using unsterilized medical instruments and other problems have cropped up at other VA hospitals around the nation, Zacchea said.

“These sorts of things are not acceptable in a private medical facility,” he said. “There seems to be this mindset that because it’s the VA and it’s government money, it’s OK and it’s not.”

Zacchea said he hopes the legislators’ visit to the Atlanta hospital on Monday will spur changes and that people responsible for problems will be held accountable on both the local and national levels.

“Overall as a system, it’s a mess,” he said. “The situation is getting worse, not better.”