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Two managers still working at the Albuquerque Veterans Affairs Medical Center encouraged staff to manipulate medical appointment records to hide long wait times, according to a newly released investigative report by the VA’s Office of Inspector General.

The Office of Inspector General’s investigation was opened more than two years ago at the urging of Sen. Tom Udall, D-N.M. Eighteen current and former employees were interviewed, including several who said the practice of altering or entering incorrect information about appointments was an effort to “underreport wait times,” according to the seven-page report released Friday.

Udall told the Journal on Friday that the confirmation of scheduling manipulation was “very troubling.”

“Our veterans have earned the best care we can provide, and the appointment scandal showed a disturbing disregard for health and safety of our heroes,” the senator said.

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The investigation didn’t find specific harm to patients caused by the long-standing practice.

Also, no link was found between the altered records, which showed veterans were being seen by medical staff sooner than they were, and positive performance appraisals and bonuses that were given to five VA medical center managers.

“Two VA officials – a nurse manager and a business manager – were identified as having played an active role in encouraging this activity,” the Office of Inspector General concluded.

The two managers were not identified. Their employment status and possible disciplinary action against them is under review by the VA’s Office of Accountability Review.

The controversy involving manipulated wait times appeared to be a systemic problem with the national VA health system in 2014, leading to the resignation in May 2014 of VA Secretary Eric Shinseki. Corrective action was ordered in New Mexico the next month.

A national VA audit in 2014 identified more than 1,000 veterans who had been waiting three months or more for initial medical appointments within the New Mexico system. When local VA officials contacted those veterans, they learned that 21 people died while waiting to see a doctor.

The Office of Inspector General report released Friday found that 19 of the deceased signed up for benefits but never availed themselves of care.

Of the remaining two, one was waiting for an audiology appointment, while the other was waiting for a cardiology diagnostic test. The VA Medical Center staff “determined that no patient harm resulted from a delay of care.”

A second agency, the Office of Inspector General’s Office of Healthcare Inspections, also reviewed the electronic records of the 21 patients and concluded there was no evidence that a delay in scheduling resulted in any patient’s death.

“We have taken meaningful steps including additional training and oversight, to ensure the improper scheduling practices of two years ago have been corrected,” Deputy Secretary of Veterans Affairs Sloan Gibson said in a statement Friday. “In addition, we have made substantial investments to ensure we have the right staff, facilities, and tools to improve access to care for Veterans in New Mexico and across the country.”

He added that VA medical staff in New Mexico has undergone aggressive training and retraining of its personnel responsible for scheduling patients to “ensure that there is no confusion in scheduling procedures.”

With an increase in staff and the opening of extended clinic hours, the current average wait time to see a medical provider in New Mexico’s VA health system is 3.36 days for primary care, 4.73 days for specialty care, and 3.68 days for mental health care.

Udall told the Journal he appreciates the VA’s reforms, “and as a member of the appropriations subcommittee that oversees the VA’s budget, I will continue to monitor the VA to ensure we don’t slip backward.”

The OIG investigation didn’t render any conclusions as to why the “misreporting” of appointments occurred.

Udall asked for the investigation after sharing with the OIG a local newspaper article that was “critical of local scheduling practices at the Raymond G. Murphy VA Medical Center,” the report said.