VA watchdog investigates psych ward breakdowns at Atlanta hospital

The Atlanta VA Medical Center installed anti-climbing fences on its parking decks in 2016. The $850,000 project was in response to a pair of incidents where suicidal veterans threatened to jump, but were talked down. BRAD SCHRADE/ BSCHRADE@AJC.COM

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The Atlanta VA Medical Center installed anti-climbing fences on its parking decks in 2016. The $850,000 project was in response to a pair of incidents where suicidal veterans threatened to jump, but were talked down. BRAD SCHRADE/ BSCHRADE@AJC.COM

Investigators review allegations about filthy and unhealthy conditions in hospital’s psychiatric unit

A watchdog with the U.S. Department of Veterans Affairs is investigating allegations that the psychiatric unit at the Atlanta VA Medical Center is plagued by filth and has disregarded COVID-19 protocols throughout the pandemic.

The inpatient unit cares for some of the VA’s most vulnerable veterans, including those suffering from post-traumatic stress disorder, suicidal thoughts and other mental health challenges. Investigators for the VA’s Office of the Medical Inspector were at the veterans hospital near Decatur on Wednesday looking into official complaints filed by two employees, hospital spokesman Derrick Smith confirmed.

The investigation was prompted after one of the employees filed a complaint with the U.S. Office of Special Counsel this spring. The special counsel’s office found “a substantial likelihood of wrongdoing” based on the information and referred the matter to the VA secretary’s office for further investigation, according to a July 5 letter by an attorney in the special counsel’s office.

The Atlanta Journal-Constitution obtained documents that one of the employees submitted to the Medical Inspector’s investigators.

One of the primary allegations centered on the lack of cleanliness and general poor living conditions on the unit. Supporting documents provided to investigators show that several nurses and veterans raised concerns and filed internal complaints about unsanitary conditions at the psychiatric unit.

Roaches crawl across the floors and a sink exploded with “black sludge” that went all over the floor, ceiling and walls of a patient treatment room, according to service requests dated July 2022. Veterans and staff consistently reported mold and no hot water in the unit’s showers.

“After my shower, I tremble for over 2 hours from cold,” one 74-year-old combat veteran wrote on his December 2021 complaint form.

Investigators are also reviewing allegations that the psychiatric unit, which is on the fourth floor of the hospital, has continually failed to follow COVID-19 protocols over the past two years.

Staff and patients have become sick because patients who test positive for COVID-19 are not effectively isolated and the unit is not following the process for tracking infections, according to documents and statements provided to investigators. One anonymous complaint that was provided to investigators was as recent as June. It echoed concerns that have been shared with hospital management throughout the pandemic, records show.

A nurse emailed Atlanta VA hospital director Ann Brown and others in June 2020 about their “grave concern,” saying social distancing was allegedly not enforced in living spaces. Beds were placed less than six feet apart and group therapy sessions were cramped, the email said. The nurse also said that patients exposed to COVID were allowed to mingle with other patients and staff.

“We firmly believe that ... leadership does not care about 4psy,” they wrote, referring to the psychiatric unit. “We, inpatient mental health workers, have been described by leadership as ‘low on the totem pole.’”

Investigators have also received complaints and documents that outline concerns about staffing shortages and their impact on the unit.

Staff charts show at times over the past two years there’s been only a handful of nurses on the unit caring for as many as 30 or more patients. Some staff are left to monitor several patients who are supposed to be looked after one-on-one due to their unpredictable or dangerous behaviors, according to emails the AJC reviewed.

One nurse filed several complaints to a union called National Nurses United as well as a Veterans Health Administration safety tracking system in June and July. They expressed concerns about staffing levels and nurse burnout on the psychiatric unit, records show.

“This dangerous staffing is due to negligence on nursing management’s part,” the nurse said in one of their reports to the Veterans Health Administration system. “With about 10 beds open for admissions there is a real good potential to create an even more dangerous crisis.”

And staffing shortages and inconsistent staffing aren’t good for patients either, a nurse pointed out in a May 2022 email to the chief of Atlanta VA’s mental health services.

“Imagine pouring your heart out to one nurse and building that trust level to finally take that medication or finally feeling good .... then having to start all over,” the nurse wrote.

The inpatient unit has 40 beds, but at times over the past two years the capacity has been capped because of staffing shortages or other problems on the unit, according to information provided to investigators.

The Atlanta VA has had a history of problems with its care of veterans with mental health issues. A series of federal audits in 2013 uncovered mismanagement that was connected to the deaths of three veterans. Two men died after staff failed to connect them to a psychiatrist, one by suicide and another by a drug overdose. The third veteran also died of a drug overdose after another patient gave him drugs.

In 2016, the hospital installed special anti-climbing fencing on its parking decks after incidents involving suicidal veterans who threatened to jump. In 2019, the facility named a new director shortly after a veteran shot himself to death outside the hospital’s entrance.

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Atlanta VA Director Ann Brown makes remarks outside the VA Medical Center on Clairmont Road in 2020. Brown has been Atlanta VA's director since 2019. (Jenni Girtman for The Atlanta Journal-Constitution)

Credit: Jenni Girtman

Atlanta VA Director Ann Brown makes remarks outside the VA Medical  Center on Clairmont Road in 2020. Brown has been Atlanta VA's director since 2019.  (Jenni Girtman for The Atlanta Journal-Constitution)

Credit: Jenni Girtman

Combined ShapeCaption
Atlanta VA Director Ann Brown makes remarks outside the VA Medical Center on Clairmont Road in 2020. Brown has been Atlanta VA's director since 2019. (Jenni Girtman for The Atlanta Journal-Constitution)

Credit: Jenni Girtman

Credit: Jenni Girtman

The Atlanta VA leadership offered few details about the current complaints. The hospital issued a statement to the AJC confirming that it is conducting its own internal review. Atlanta officials look forward to the medical inspector’s findings, the statement said.

“We welcome all external reviews when assessing ways to improve care for our Veterans,” Smith, the hospital spokesman, wrote in an email statement. “We are committed to addressing any opportunities for improvement.”

Investigators have 60 days to look into the current allegations, but the investigation could take longer, according to the special counsel attorney’s letter.

“These investigations usually take longer, and agencies frequently request and receive extension of the due date,” the letter said, later noting: “This remains an open matter under investigation until the agency’s final report is forwarded to the President and Congress.”