A federal investigator has described a “troubling pattern” of Veterans Affairs Department officials downplaying or ignoring whistleblowers at facilities nationwide, resulting in patients receiving deficient, delayed and in some cases no needed medical attention.
In a letter Monday to President Obama, Carolyn Lerner of the U.S. Office of Special Counsel said that “too frequently, the VA has failed to use information from whistleblowers to identify and address systemic concerns that impact patient care.”
Lerner said the VA, and particularly the agency’s Office of the Medical Inspector (OMI), consistently have used a "harmless error" defense, where the department acknowledges problems but claims patient care is unaffected.
“This approach has prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans,” she said. “As a result, veterans' health and safety has been unnecessarily put at risk."
Lerner cited several examples, including a case at the VA facility in Grand Junction, Colo., where she said officials downplayed a whistleblower’s concerns that drinking water had elevated levels of Legionella bacteria, and that standard maintenance and cleaning procedures required to prevent bacterial growth weren't performed.
After the OMI identified no "clinical consequences" resulting from the unsafe water conditions, officials determined there was no substantial and specific danger to public health and safety.
In another case, Lerner said the OMI failed to adequately respond to whistleblower allegations that the VA facility in Fort Collins, Colo., had practiced deceptive patient scheduling to artificially reduce patient wait times. Schedulers were placed on a "bad boy" list if their scheduled appointments were greater than 14 days from the recorded "desired dates" for veterans.
Other examples Lerner cited include:
• In Montgomery, Ala., OMI confirmed a whistleblower's allegations that a pulmonologist copied prior provider notes to represent current readings in more than 1,200 patient records, likely resulting in inaccurate patient health information being recorded. But OMI stated that it couldn't substantiate whether the practice endangered patient health.
• In Buffalo, N.Y., OMI confirmed a whistleblower's report that health care professionals didn’t always comply with VA sterilization standards, but didn’t believe the problem affected patient safety.
• In Little Rock, Ark., OMI substantiated a whistleblower's allegations regarding patient care, including one incident when suction equipment was unavailable when it was needed to treat a veteran who later died. OMI later concluded the medical treatment the patient received met care standards.
• In Harlingen, Texas, the VA Deputy Under Secretary for Health confirmed a whistleblower's allegations the facility didn’t comply with rules on the credentialing and privileging of surgeons. The VA also found that the facility wasn't paying fee-basis doctors in a timely manner, resulting in some refusing to care for VA patients. But the VA found there wasn't substantial and specific danger to the public health and safety resulting from the violations.
Lerner, who said her office is reviewing more than 50 whistleblower cases at VA facilities – all of which allege threats to patient health or safety — recommended the VA appoint a high-level official to assess how the department responds to whistleblower claims.
“I remain concerned about the department's willingness to acknowledge and address the impact these problems may have on the health and safety of veterans,” she wrote.
Acting VA Secretary Sloan Gibson said he had started a departmental review due to be completed within 14 days.
On Capitol Hill, the Senate passed legislation earlier this month with overwhelming bipartisan support that would make it easier for veterans to receive VA-paid treatment from private doctors.
The bill, similar to a House measure that passed unanimously, would allow veterans to seek care through non-VA providers for the next two years when the department cannot give the veteran a timely appointment, or if a veteran lives more than 40 miles from the closest VA medical facility. The VA would pick up the tab.