In the wake of backlash against the Department of Veterans Affairs for not cracking down hard enough on employee accountability, its watchdog group released three new reports this week that demonstrate continuing problems at VA hospitals.
The VA inspector general’s office released reports on hospitals in Ohio, Maryland and Virginia that showed evidence of mismanagement and staff training problems.
The first report, released Tuesday, evaluated the VA medical center in Cleveland, Ohio, and found some staff were not trained in how to issue barcode identifiers for patient files, and the hospital attributed it to “difficulties that contract employees have ‘getting into the system’ for basic matters like background and fingerprinting and issuance of personal identity verification badges, pagers, or lockers.” Until such contract employees were fully integrated into the VA system, they had no access to equipment, computers or training.
In the process, “some staff shared test operator identifications and improperly entered patient identifiers,” the IG report concluded, so the laboratory staff in the hospital were unable to match the correct lab results with the correct patient files. Staff were also found to have not been trained in facility policy and procedure, but were performing tests on patients.
The second report, also released Tuesday, evaluated the mental health residential rehabilitation program at the Baltimore VA hospital. The IG’s office found that staff at the Baltimore clinic had not been documenting significant clinical events in patients’ electronic health records, including “pertinent facts, findings, and observations about a patient’s health history, past and present illnesses, examinations, tests, treatments, and outcomes,” leaving some patients with incomplete records.
The third evaluation was of the Salem, Virginia VA medical center, and the IG report found that half of the inspected areas of the hospital “did not have medications awaiting destruction stored separately from those available for administration.” Medication is also supposed to have an expiration date posted on the vial, and in half of the hospital’s inspected areas, the watchdog group found that vials were labeled with incorrect expiration dates.
The hospital also had 10 independent practitioners working with patients, all of whom had “non-allowed” information in their files. The IG also found that equipment needed replacing — three of seven units had damaged wheelchairs — and a third of the clinics failed to properly disinfect equipment between patients.
The VA has been criticized in recent weeks for demoting two senior executives instead of firing them for a scheme they orchestrated to transfer to new posts. As part of this scheme, they also took nearly $400,000 in relocation bonuses the IG’s office concluded they didn’t deserve, but the VA has not made any moves to recoup the money.
On Thursday, VA officials announced that they were putting the demotions on hold after a paperwork mix-up did not allow the employees to have complete access to evidence approving the demotion and is giving them an extended appeals process, drawing the ire of lawmakers and veteran service organizations.
The beleaguered agency has been under intense scrutiny since an IG report was released last year saying that 40 patients at a Phoenix, Arizona hospital died while languishing on a secret waiting list manipulated by employees to make wait times seem shorter than they were. The scandal led to former VA Secretary Eric Shinseki’s resignation and calls for reform from lawmakers in Congress.