Meanwhile, we’re going to be stuck reporting incidents such as those detailed in the story below, like:
Lexington, Ky., Two chest X-rays showed a veteran had tumors in his lungs, but he wasn’t told until more than eight months later
Albany, N.Y., – Vet dies from Legionnaire’s disease contracted at VA facility
Asheville, N.C., – A vet’s leg was broken during surgery and not initially treated
Lebanon, Pa., – A vet receiving surgery on his nose has his face set on fire
Sadly, that’s just naming a few. How can we make this all stop? The VA would say more money, but new coverage shows that the Department isn’t even using the money it claimed it so desperately needed. The VA is scared to change, and is dying on a hill protecting their employees’ jobs, pensions and bonuses. For example, Congress allocated $10 Billion to the Department to institute and promote veterans’ choice to seek outside care, but conveniently, much of the money hasn’t been used and they now want to use it for other purposes.
We have to stop putting our faith in the idea that bureaucrats will help change bureaucrats. It’s been made clear that bureaucrats instead will serve their own interests. We have to fundamentally reform and fix the VA from the inside out – and we can start by pushing for more VA Accountability and more Independence for veterans to make their own choices when it comes to their health care. After all – veterans chose to serve their country, they should be able to choose their own doctor.
“The cases range from missed diagnoses to failures during surgery — one veteran’s face was set on fire during an operation in Lebanon, Pa. — and from misuse of funds to personnel issues — an intensive care unit at the Tucson VA was beset by a “cauldron of interpersonal tensions and management difficulties,” the inspector general found.
They also included reports involving concerns about providers prescribing potentially questionable amounts or combinations of narcotics to veterans in Tampa, Fla., Valdosta, Ga., and Lexington, Ky. Five months after the inspector general reached similar findings about providers in Tomah, Wis., but did not release a public report last year, a 35-year-old Marine Corps veteran died from mixed drug toxicity as an inpatient at the facility.
The range of outcomes in the newly released reports indicate the inspector general may have lacked a uniform standard for deciding when to issue public findings. Roughly 50 reports dismissed allegations of wrongdoing, but more of them — 59 — contained substantiated claims.
Almost all the investigations in the newly released reports were generated by tips from VA employees, veteran patients, their family members or the public.
They involved allegations at VA facilities in 42 states that ranged from the unsubstantiated and seemingly inane — one complainant alleged a nurse abused an elderly veteran patient by feeding him a doughnut covered in hot sauce — to substantiated complaints of serious harm or death.
A veteran dependent on a ventilator was checked into a unit with staff not competent to deal with such patients in West Palm Beach, Fla. He was later found unresponsive, disconnected from the ventilator and in cardiac arrest, but was revived.
Staff at the Wichita, Kan., VA medical center did not resuscitate a veteran after his advance directive to be resuscitated was not scanned into his chart. A veteran contracted Legionnaire’s disease in an intensive care unit at the VA in Albany, N.Y., and died.
In Asheville, N.C., a veteran’s leg was broken during surgery and not initially treated. In the Lebanon, Pa., case, a veteran was having surgery to remove a cancerous lesion on his nose when his face was set on fire in the operating room.
In Lexington, Ky., two chest X-rays showed a veteran had tumors in his lungs, but he wasn’t told until more than eight months later, after providers at a private facility diagnosed his lung cancer, which he later died from. A veteran went to a VA emergency room in San Diego with chest pain and was diagnosed with acid reflux. He died the next day from a heart attack.
In Pittsburgh, providers had implanted potentially defective aortic stents in 31 veterans, and two subsequently developed leaks that required surgery to remove the stents. Manufacturer Guidant provided a sample patient notification letter to health care providers, but the Pittsburgh VA did not inform its veteran patients.
With allegations of inappropriate narcotic prescription practices, inspectors found a primary care physician in Lexington, Ky., was prescribing opiates to disproportionately more patients than most other physicians at the facility, and in Tampa, Fla., another primary care doctor also was prescribing controlled substances at a “significantly higher rate” than his peers. A psychiatrist in Valdosta, Ga., was counseled about prescribing antidepressants in combination with other potentially sedating agents.
As with what happened in Tomah, Wis., inspectors did not find evidence of wrongdoing or patient harm in those cases, and closed them without public reports.”