Deaths at Atlanta VA hospital prompt scrutiny

By By CHRISTINA A. CASSIDY

ATLANTA (AP) — One mental health patient with a history of substance abuse and suicidal thoughts was left alone in a waiting room inside the Atlanta VA Medical Center, where he obtained drugs from a hospital visitor and later died of an overdose.

Another patient wandered the 26-acre campus for four hours, picking up his prescriptions from an outpatient pharmacy and injecting himself with testosterone before returning voluntarily to his room.

The cases at the Atlanta VA Medical Center are just the latest in a string of problems that have surfaced at Veterans Affairs facilities nationwide, prompting outrage from elected officials and congressional scrutiny of the largest integrated health care system in the country, with nearly 300,000 employees. In fiscal year 2011, the VA served nearly 6.1 million patients at its 152 medical centers.

"There are some that say the VA has just gotten too big and it is unmanageable at any level," said Rep. Jeff Miller, chairman of the House Committee on Veterans' Affairs. "There are those that are trying every day to provide quality and timely health care within the system. But we continue to receive information regarding veterans' suicides, delays in receiving mental health care which is totally unacceptable when we are constantly confronted with a number of 18 to 22 veterans a day committing suicide."

In recent years, there have been inquiries into the Pittsburgh VA system after five people died of Legionnaire's disease and the Buffalo, N.Y., VA hospital where at least 18 veterans have tested positive for hepatitis. There have also been whistleblower complaints ranging from improper sterilization procedures to radiology tests left unread at a VA facility in Jackson, Miss. All the while, the need continues to grow. In the area of mental health alone, it's estimated that 13 percent to 20 percent of the 2.6 million service members deployed to Iraq and Afghanistan have symptoms of post-traumatic stress disorder.

"It's not just Atlanta. There are issues throughout the United States," said Miller, a Republican from Pensacola, Fla. "I would hope that senior officials within the Department of Veterans Affairs would put their foot down because they are the ultimate supervisor when it comes to these problems."

At the Atlanta VA Medical Center, two reports issued in mid-April by the Department of Veterans Affairs' Office of Inspector General detailed allegations of mismanagement and poor patient care linked to three deaths. The case of a fourth veteran, a man in a wheelchair who came to the Atlanta VA emergency room complaining of hearing voices but was not admitted and later found in a locked hospital bathroom dead of an apparent suicide, was a turning point for Miller. He is planning a second field hearing in the Atlanta area to address the problems that have been uncovered.

"We will air this out in a public setting so that people will understand, especially those at the VA, that there is an oversight component that is watching them and hopefully helping veterans and their families get the care they need, the care they deserve and the care they have earned," said Miller, who has also been critical of performance bonuses paid to senior officials at the VA.

In responses to the VA, officials at the Atlanta VA Medical Center said they had already taken steps to address the issues cited in the reports, including new policies requiring visitors to be supervised and closer patient monitoring. And patient satisfaction appears to remain high at the Atlanta facility, which serves a population of some 87,000 veterans with an operating budget of more $500 million. One of the Inspector General reports noted patients in the mental health unit at the Atlanta VA facility had higher positive satisfaction rates than the national VA average.

The interim director has been replaced, and a former deputy assistant secretary, Leslie B. Wiggins, has been brought in to take over. Wiggins, during a May 20 news conference, promised to reach out to staff and local veterans groups, listen to their concerns and "offer a way forward."

"The employees here are committed to serving veterans, first and foremost," Wiggins said, according to remarks provided by her office. "One of my primary goals is to ensure Atlanta has an environment that fosters physical and psychological safety. We want our veterans to know that they are receiving great care here in Atlanta."

Rep. David Scott, a Democrat whose district is served by the center, met with Wiggins in Washington before she arrived in Atlanta and said he was hopeful critical changes would be made.

"Our veterans deserve so much better. They put their lives on the lines for us. They go the extra mile for us and to have this sad, shameful situation at the VA center is just unacceptable," Scott said. "It was just colossal mismanagement and when you have that, you have to bring in new people."

Scott said he was impressed by Wiggins experience in labor management relations as well as nursing and expects staffing changes.

"This is your own inspector general coming out and clearly pointing out these things. We have four soldiers, veterans who are dead because of actions taken by or lack of actions taken by the management at that hospital," Scott said. "You couldn't tolerate that at any other hospital. Heads would roll. They would be gone."

In one report, investigators found the Atlanta facility did not sufficiently address patient care safety, failed to monitor patients and did not have adequate policies for dealing with contraband, visitation and drug tests. In the case of the man who overdosed on drugs from a hospital visitor, the report said the man was searched when he returned to his room and given a drug test, but it was later determined another patient had provided the urine. Investigators said the facility had not provided staff with a policy for collecting urine prior to the man's death, which should include securing the bathroom or direct observation. Investigators also noted the unit had no written policy on patient visitors.

In addition to the patient who said he "roamed through the building" after an escort failed to meet him after a medical appointment, another patient with schizophrenia disappeared for several hours after a dental appointment before returning to the unit saying he "got lost."

As part of the report, investigators recommended the VA establish national policies that address contraband, visitation, urine testing and escorts for inpatients of mental health units. The VA has agreed and plans to implement those policies by Sept. 30.

A separate report linked two additional deaths to the facility and its referral program to outside mental health providers. Investigators noted the Atlanta VA Medical Center had referred more than 4,000 patients since 2010 but did not know the status of those patients. "The facility managers were aware that a large number of patients were 'falling through the cracks,'" investigators wrote in the April 17 report.

"There is no case management or follow-up," said one unidentified staff member quoted in the report. "I do not have a list of how many people are being seen in the community. I do not know how to get that information unless we call 4,000 or something vets and ask them."

Investigators noted some 10 employees were tasked with managing and providing oversight for the more than 4,000 patients referred under the program. "These employees also described challenges in program oversight, inadequate clinical monitoring, staff burnout and compromised patient safety due to the unmanageable volume of patients assigned to the program," investigators said in the report.

One patient who died had a long history of mental health issues including suicidal behavior. He was evaluated and prescribed medicine for depression. A follow-up appointment wasn't scheduled until four weeks later, and the patient committed suicide during that time, according to the report.

Rep. Miller had drafted legislation that would specifically address mental health care within the VA system, noting that problems have persisted even though programs, budget, and staff have increased significantly since 2007. The bill would require the VA to contract with civilian contractors for mental health care while also requiring the VA to keep closer tabs on the care that is provided and ensuring certain measures like quality and timeliness of care meet expectations.

"Last year, the IG found that more than half of the veterans who go to VA seeking mental health care services wait fifty days on average to receive even an initial evaluation," Miller said in remarks at a May 21 hearing. "This year, the IG found that thousands of Georgia veterans had fallen through giant cracks in VA's mental health care system and may or may not have received the care they so desperately needed. We cannot wait to see what next year brings."

For a few of those seeking care at the Atlanta VA on a recent afternoon, the problems haven't affected them.

"I haven't seen it. It's probably happening but I just haven't seen it," said Lester Paulus, 73, a retired Navy veteran from Canton, Ga., who has had eye surgery and successful cancer treatment at the Atlanta VA hospital. "I've had good treatment here and good care."

"I don't have any complaints at all," said Charles Coalley, 66, an Army veteran from Raybun County, Ga.

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