In a six page letter to President Obama dated June 23, 2014, Carolyn Lerner, head of the U.S. Office of Special Counsel, detailed 10 cases where the VA admitted serious deficiencies in patient care yet denied it had any impact on the veterans’ health, public safety or patient rights.
In one case, the VA’s OMI (Office of the Medical Inspector) said it could not find “a danger to public health and safety,” although its investigators confirmed that nearly 3,000 veterans at a VA facility in Fort Collins, Colorado, were unable to reschedule canceled appointments, including veterans whose “routine primary care needs were not addressed” as a result.
Another case brought forward by a VA psychiatrist showed that a patient with a 100 percent service related psychiatric condition was in the Brockton, Massachusetts mental health care facility for seven years before treatment recommendations were noted on his chart.
Another veteran with “significant” mental health issues waited more than eight years after being admitted before receiving a psychiatric evaluation.
The letter also details significant problems at the VA facility in Jackson, Mississippi and found the administration’s response “unreasonable.”
- A shortage of providers caused the facility to frequently cancel appointments for
veterans. After cancellations, providers did not conduct required follow-up, resulting in situations where “routine primary care needs were not addressed.”
- The facility “blind scheduled” veterans whose appointments were canceled, meaning
veterans were not consulted when rescheduling the appointment. If a veteran subsequently called to change the blind-scheduled appointment date, schedulers were instructed to record the appointment as canceled at the patient’s request. This had the effect of deleting the initial “desired date” for the appointment, so records would no longer indicate that the initial appointment was actually canceled by the facility.
- At the time of the OM! report, nearly 3,000 veterans were unable to reschedule canceled appointments, and one nnrse practitioner alone had a total of975 patients who were unable to reschedule appointments.
- Staff were instructed to alter wait times to make the waiting periods look shorter.
- Schedulers were placed on a “bad boy” list if their scheduled appointments were greater than 14 days from the recorded “desired dates” for veterans.
“… in the fantasy land inhabited by VA’s Office of the Medical Inspector, serious patient safety issues apparently have no impact on patient safety. It’s impossible to solve problems by whitewashing them or denying they exist,” chairman of the House Committee on Veterans Affairs, Florida Congressman Jeff Miller (R-Pensacola), released in a statement on the OSC Letter to President Obama.