June 23, 2014

USA: Veterans Affairs Watchdog Downplayed Medical Care Problems, Probe Finds; Report Claims Legitimate Whistleblowers' Critiques Were Ignored.

The Wall Street Journal
written by Michael M. Phillips and Ben Kesling
Monday June 23, 2014

WASHINGTON — A Department of Veterans Affairs internal watchdog created to safeguard the medical care provided to former service members instead routinely played down the effect of treatment errors and appointment delays, a federal special counsel alleged Monday.

In a letter to President Barack Obama, U.S. Special Counsel Carolyn Lerner said the VA Office of the Medical Inspector has repeatedly undermined legitimate whistleblowers by confirming their allegations of wrongdoing, but dismissing them as having no impact on patient care.

The strongly worded critique adds a new layer to the veterans-care scandal that has rocked the VA and the Obama administration in recent months.

Among the cases that whistleblowers reported to the special counsel:

A veteran wasn't given his first comprehensive psychiatric evaluation until he had spent eight years as a resident of a Brockton, Mass., VA psychiatric unit, in 2011.

Drinking water at the VA facility in Grand Junction, Colo., was tainted with elevated levels of Legionella bacteria, which can cause a form of pneumonia, and standard maintenance and cleaning procedures weren't performed.

A VA pulmonologist in Montgomery, Ala., portrayed past test readings as current results in more than 1,200 patient files, "likely resulting in inaccurate patient health information being recorded," Ms. Lerner wrote.

In Buffalo, N.Y., VA staff sometimes mishandled sterile surgical instruments and failed to wear required protective gear.

In each of these cases, VA whistleblowers brought the information to the special counsel, an independent federal entity that is charged with enforcing whistleblower-protection laws. The special counsel passed it along to the Office of the Medical Inspector.

The VA medical inspector concluded that the hospitals' failings, while accurately reported by the whistleblowers, didn't threaten veterans' health or safety, even when the VA inspector general had concluded that similar faults compromised care in other cases, according to the letter from Ms. Lerner.

Referring to the Brockton psychiatric unit, the Office of the Medical Inspector wrote, "OMI feels that in some areas [the veterans'] care could have been better, but OMI doesn't feel that their patient's rights were violated," according to OMI documents cited in Ms. Lerner's letter.

Ms. Lerner called such statements "a serious disservice to the veterans who received inadequate patient care for years after being admitted to VA facilities."

"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," wrote Ms. Lerner.

Acting VA Secretary Sloan Gibson said the VA accepts the Office of Special Counsel's recommendations, and ordered a full review of the VA's Office of Medical Inspector's operation to be completed in two weeks.

"I am deeply disappointed not only in the substantiation of allegations raised by whistleblowers, but also in the failures within VA to take whistleblower complaints seriously," he said in a written statement.

The special counsel's allegations are the latest blow to the VA, which was rocked this spring by revelations that some employees doctored records to make appointment wait-times appear far shorter than they were. The disclosure prompted then-Secretary Eric Shinseki and other top VA officials to resign.

"There are many instances where there have been whistleblowers that have resulted in investigations," Sen. Jerry Moran (R., Kan.), a member of the Senate Committee on Veterans' Affairs, said Sunday. "We have no idea if anything has come from those investigations or reports."

Since the scheduling scandal surfaced, the VA inspector general, a separate internal watchdog, has examined operations at dozens of medical VA facilities across the nation. The VA has conducted its own reviews. Federal investigators have said they are working to determine whether criminal charges will be brought in any of the cases.

Though the Office of Special Counsel has the authority to refer whistleblower-retaliation cases to the Justice Department for criminal prosecution, the agency said its current findings don't involve such potentially criminal retribution.

Mr. Gibson has been battling to control the crisis, traveling to VA facilities around the country and making appearances to reassure veterans, the public and Congress. He said Thursday that the VA had contacted 70,000 veterans to get them quick appointments.

In an internal message this month to the VA's 341,000 staff, Mr. Gibson promised protection for those who reported misdeeds in agency operations.

"Relatively simple issues that front-line staff may be aware of can grow into significantly larger problems if left unresolved," Mr. Gibson said. "In the most serious cases, these problems can lead to and encourage improper and unethical actions."

Joe Davis, a spokesman for the Veterans of Foreign Wars, a veterans-advocacy group, welcomed the special counsel's report. "What we want is more scrutiny," Mr. Davis said. "The more eyes that are looking at this means more scrutiny, and that leads to more accountability," he said.

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