Feds find 'blatant disregard' for veteran safety at VA nursing home among the nation's worst

Donovan Slack, USA TODAY, and Andrea Estes, The Boston Globe | USA TODAY

Show Caption Hide Caption Life in a VA nursing home: One veteran’s story Don Ruch’s family thought round-the-clock care would help him recuperate, but he ended up in intensive care in septic shock, suffering from “severe” malnutrition, bedsores on his pelvis and back, a burn on his right thigh and a trauma wound.

BOSTON – Staffers at the Department of Veterans Affairs nursing home in Brockton, Massachusetts – rated among the worst VA nursing homes in the country – knew this spring that they were under scrutiny and that federal investigators were coming to visit, looking for signs of patient neglect.

Still, when investigators arrived, they didn’t have to look far: They found a nurse and a nurse’s aide fast asleep during their shifts. One dozed in a darkened room, the other was wrapped in a blanket in the locked cafeteria.

The sleeping staffers became a focal point of a new, scathing internal report about patient care at the facility, sparked by a nurse’s complaint that veterans were getting substandard care, according to a letter sent late last month to President Donald Trump and Congress by the agency that protects government whistleblowers.

“We have significant concern about the blatant disregard for veteran safety by the registered nurses and certified nurse assistants,” agency investigators wrote in a report about the 112-bed facility. The Brockton facility is a one-star nursing home, the lowest rating in the agency’s own quality ranking system.

VA spokeswoman Pallas Wahl said officials took “immediate corrective action,” and the employees caught sleeping no longer work there.

The problems at the Brockton nursing home are the latest to surface in a review of VA nursing home care by USA TODAY and The Boston Globe.

In June, the news organizations revealed the VA’s secret quality ratings showed that care at more than 100 VA nursing homes across the country scored worse than private nursing home averages on a majority of key quality indicators last year.

In response to questions from USA TODAY and the Globe, the VA released nursing home ratings that had been kept secret for years, potentially depriving veterans and their families of crucial health care information.

At the time, the VA said it was releasing inspection reports the agency withheld from the public for nearly a decade. Five months later, none has been released.

VA spokesman Curt Cashour told USA TODAY that the agency is working with an outside contractor to remove patient information from reports. He said the VA expects to release "publicly redacted versions of the most recent reports" around Christmas.

That's not good enough for Leslie Roe, whose husband of 38 years walked out of a supposedly secure unit at the VA nursing home in Tuskegee, Alabama, last year and was never found.

Roe, who had Navy veteran Earl "Jim" Zook declared dead this year, wants the VA to immediately release three years' worth of inspection reports – the standard for private-sector nursing homes whose reports are posted on a federal website, NursingHomeCompare.

"It's just a shame the way the VA is," she said. "It can't help Jim, but maybe it can help just one other person."

The reports can include incidents of poor care and conditions that can be a tip-off to prospective or current residents and their families about problems with staffing or neglect at a facility.

"What are they hiding? Why wouldn’t you release it?" asked Amy Leise, whose uncle, Vietnam veteran Don Ruch, suffered from malnutrition and bedsores last year at a VA nursing home in Livermore, California.

"It feels like the government is immune from accountability and responsibility, where in other settings that wouldn't be the case," she said.

VA releases new nursing home ratings

The VA released an updated set of star ratings. They show 45 of its nursing homes received the lowest one out of five stars for quality as of June 30. That’s down from 58 in March. The VA has 133 nursing homes that serve 46,000 infirm veterans each year across the country.

More: Secret VA nursing home ratings for 2017

At the nursing home in Brockton, residents were, on average, more likely than residents of other VA nursing homes to deteriorate, feel serious pain or suffer from bedsores, according to agency data. They were nearly three times as likely to have bedsores than residents of private nursing homes.

Licensed practical nurse Patricia Labossiere said she complained to the Office of Special Counsel, a federal whistleblower agency, this year after supervisors in Brockton ignored her alerts.

“I am a no-nonsense nurse who took a vow to take care of patients,” said Labossiere, who quit in July. “We are there to be kind and treat others as we would want to be treated. I could not believe that this was how we treat the people that fought for our country.”

Labossiere said she saw instance after instance of poor patient care at the facility within days after she started working there last December. She told the federal whistleblower agency that nurses and aides did not empty the bedside urinals of frail veterans. Nurses failed to provide clean water at night and didn’t check on the veterans regularly, as required, she said. They often slept when they were supposed to be working.

She offered some specific examples: One patient had trouble breathing because his oxygen tank was empty. Another fell – his feeding tube got disconnected, and the liquid splashed onto the floor – and didn’t appear to have been monitored by staffers for hours.

The VA investigators did not substantiate those allegations, saying the patient with the empty oxygen tank suffered no ill effects. Investigators couldn’t confirm that the patient who fell had been neglected because the records were shredded “in accordance with the local policy.”

'Routinely receiving substandard care'

Wahl, the VA spokeswoman, noted that the investigators “did not find evidence of veteran harm or neglect.” She said the facility’s one-star rating is undeserved and not an “accurate reflection of the quality of care delivered to our patients."

The Office of Special Counsel ordered the VA’s Office of Medical Inspector to investigate Brockton after Labossiere’s complaint. The office turned over its report in September to special counsel Henry Kerner, who sent the findings to Trump and Congress on Oct. 23.

“Because a brave whistleblower came forward, VA investigators were able to substantiate that patients at the Brockton (nursing home) were routinely receiving substandard care,” Kerner said in an emailed statement.

This is not the first time the Brockton facility has come under fire by the Office of Medical Inspector.

In 2014, a doctor at the nursing home alleged that three veterans with significant mental health issues received “inappropriate medical and mental health care.”

Two of them went years, he alleged, without appropriate treatment. A third allegedly received psychotropic drugs for more than two years against written instructions.

Investigators largely substantiated the allegations, finding that two veterans with significant psychiatric issues did not receive adequate treatment for years. They did not substantiate the allegation that a third received improper medication.

More: Secret VA nursing home ratings hide poor quality care from the public

More: Secret data: Most VA nursing homes have more residents with bedsores, pain, than private facilities

More: Bedsores, neglect, alleged abuse: Inside low-rated VA nursing homes

More: Lawmakers demand secret VA nursing home data be released after USA TODAY, Boston Globe report