Chronicling a long list of VA whistleblower cases, Special Counsel Carolyn Lerner (this Lerner speaks) said “based on the scope and breadth of the complaints OSC has received, it is clear that the workplace culture in many VA facilities is hostile to whistleblowers and actively discourages them from coming forward with what is often critical information.”
Lerner also told the House Veterans Affairs Committee that “too often the VA has failed to use the information provided by whistleblowers as an early warning system. Instead, in many cases, the VA has ignored or attempted to minimize problems, allowing serious issues to fester and grow.”
Much of her Lerner’s statement came from a June 23 letter to the President (embedded below) in which she outlined the VA’s problems. The letter crushed the idea that once a veteran finally got an appointment they received good care.
The VA, and particularly the VA’s Office of the Medical Inspector (OMI), has consistently used a ‘harmless error’ defense, where the department acknowledges problems but claims patient care is unaffected,” she said, quoting her June 23 letter to Obama. “This approach hides the severity of systemic and longstanding problems, and has prevented the VA from taking the steps necessary to improve quality of care for veterans.
Lerner told about patient neglect disclosures from a VA psychiatrist whistleblower at a longterm mental health-care facility in Brockton, Mass.
A “veteran was admitted to the facility in 2003, with significant and chronic mental health issues,” she said. “Yet his first comprehensive psychiatric evaluation did not occur until 2011, more than eight years after he was admitted, when he was assessed by the whistleblower. No medication assessments or modifications occurred until the 2011 consultation.”
Another example from Lerner’s letter”
In Grand Junction, CO, OMI substantiated a whistleblower’s concerns that the facility’s drinking water had elevated levels of Legionella bacteria, and standard maintenance and cleaning procedures required to prevent bacterial growth were not performed. After identifying no “clinical consequences” resulting from the unsafe conditions for veterans, OMI determined there was no substantial and specific danger to public health and safety.
There are other examples in Lerner’s letter that are so bad they will make your eyes bleed.
Lerner said 30 of the complaints about retaliation have passed the initial review stage and were being further investigated for corrective action and possible discipline against VA supervisors and other executives. The complaints were filed in 28 states at 45 separate facilities, Lerner provided the figures in testimony prepared for a Tuesday night hearing before the House Veterans Affairs Committee.
Lerner said her office has been able to block disciplinary actions against several VA employees who reported wrongdoing, including one who reported a possible crime at a VA facility in New York.
The counsel’s office also reversed a suspension for a VA employee in Hawaii who reported seeing an elderly patient being improperly restrained in a wheelchair. The whistleblower was granted full back pay and an unspecified monetary award and the official who retaliated against the worker was suspended, Lerner said.
In a related development, the VA said Tuesday it was restructuring its Office of Medical Inspector following a scathing report [the June 23 letter below] by Lerner’s agency last month.
Also testifying was Katherine Mitchell a doctor at the Phoenix veterans hospital says she was harassed and humiliated after complaining about problems at the hospital, where dozens of veterans died while on waiting lists for appointments.
Dr. Katherine Mitchell said the hospital’s emergency room was severely understaffed and could not keep up with “the dangerous flood of patients” there. Mitchell, a former co-director of the Phoenix VA hospital’s ER, said in testimony prepared for the House committee that strokes, heart attacks, internal head bleeding and other serious medical problems were missed by staffers “overwhelmed by the glut of patients.”
“Ethics have never been made an official VA performance measure, and thus do not appear to be a clear administrative goal,” she said. “There seems to be no perceived financial advantage to pursuing ethical conduct. Administrative repercussions are lacking for unethical behaviors that are so routinely practiced among senior executive service employees.”
The VA has done a horrible disservice to the people who deserve the best, the people who sacrificed to protect the rest of us.