New and more revolting revelations in the V.A. scandal come each day, and yesterday was no exception. The independent Office of Special Counsel (OSC) is investigating 67 claims of retaliation against whistleblowers by supervisors, 25 of those complaints occurring since June 1, well after the scandal broke. This indicates while the nation was demanding answers for this affront to our heroes, some in the V.A. were fighting to keep the lid on the scandal. Beyond that the basic sanitary conditions were not kept at some facilities, and in some cases heath workers who did not have the proper accreditation were treating patients.
Chronicling a long list of V.A. 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 V.A. has failed to use the information provided by whistleblowers as an early warning system. Instead, in many cases, the V.A. ignored or attempted to minimize problems, allowing serious issues to fester and grow.”
Much of Lerner’s statement came from a June 23 letter to the President, in which she outlined the V.A.’s problems. The letter crushed the idea that once a veteran finally got an appointment, he received good care.
“The V.A., and particularly the V.A.’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 V.A. from taking the steps necessary to improve quality of care for veterans.”
Lerner told about patient neglect disclosures from a V.A. psychiatrist whistleblower at a long-term 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 V.A. employees who reported wrongdoing, including one who reported a possible crime at a V.A. facility in New York.
The counsel’s office also reversed a suspension for a V.A. 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 V.A. 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, who 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 V.A. 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 V.A. performance measure, and thus do not appear to be a clear administrative goal. 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 V.A. has done a horrible disservice to the people who deserve the best, the people who sacrificed to protect the rest of us.
In this video, one whistlebower testifies about the extent of the harassment:
Cross-posted at The Lid