Newly released VA reports include cases of harm, death

WASHINGTON – Almost 140 previously unreleased investigative reports by the inspector general at the Veterans Affairs Department offer a litany of instances of dysfunction or mistreatment of veterans at VA facilities across the country and show that in many cases, the department's chief watchdog trusted the VA to correct problems on its own rather than make findings public.

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, 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.

Joanne Moffett, a spokeswoman for Richard Griffin, the interim VA inspector general, maintained Wednesday that there was a standard — public reports were not released when a potential lawsuit was pending, when complaints were unfounded or when inspection officials decided VA officials had or would take care of the problems.

Since USA TODAY first reported last month that his office did not publicly release the findings of the 140 health care probes since 2006, Griffin did direct that in the future, only he or his immediate staff would be able to make such decisions.

But some members of Congress say that's not good enough. And they don't want issues to fester within the VA without congressional or public oversight. Trusting the VA will fix itself is illogical, they say.

"The only way you have any hope of fixing a bureaucracy is for public disclosure," said Sen. Ron Johnson, R-Oshkosh., who co-sponsored legislation with Sen. Tammy Baldwin, D-Madison, that would require public release in the future of inspection reports at the VA and across the federal government.

There are roughly 75 inspectors general tasked under a 1978 law to be independent watchdogs within agencies rooting out waste, fraud, and abuse and mismanagement. Among their duties is keeping Congress — and hence the public — "fully and currently informed" of problems they find, according to the law.

They can initiate investigations based on requests from Congress, on tips they get from employees or the public or upon learning separately of potential wrongdoing.

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 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, 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 was prescribing opiates to disproportionately more patients than most other physicians at the facility, and in Tampa another primary care doctor also was prescribing controlled substances at a "significantly higher rate" than his peers. A psychiatrist in Valdosta was counseled about prescribing antidepressants in combination with other potentially sedating agents.

As with what happened in Tomah, inspectors did not find evidence of wrongdoing or patient harm in those cases, and closed them without public reports.

Moffett, the spokeswoman for interim Inspector General Griffin, defended the inspector's initial decisions not to publicly release the reports and said she believes that now that they are released, people will see those decisions were warranted.

"We made the decision to publish our reports of administrative closures to lay out the basis for our decision-making and to show that we had sound reasons in closing these inspections," she said.

Moffett said that even though the reports were not initially released, they were technically available if the public or members of Congress submitted a Freedom of Information Act request. Such requests, however, would require knowledge of the reports' existence.

Contact dslack@usatoday.com. Follow @donovanslack.