Washington VA Medical Center Continues to Fail Its Patients

The VA Office of Inspector General released a report in July regarding an incident that occurred at a Washington, D.C. VA hospital in early 2019. The incident in question involved a veteran who arrived at the hospital asking to stay the night, because he or she was battling withdrawal from opioids and was having suicidal thoughts. (The report omitted all identifying factors, including sex and gender.) The VA removed the veteran.

According to Stars & Stripes, “Six days later, the veteran died of a self-inflicted gunshot wound.”

The report from the Inspector General

The Inspector General looked into the incident. What followed was a damning report outlining misconduct and acts of patient abuse, and the failure of the VA to do anything to help the patient, including:

• Bouncing the patient between 7 different doctors in a 12-hour period
• Failing to accurate asses the suicide risk of the patient
• Failing to report the doctor’s professional misconduct to the licensing board, despite the doctor saying the veteran could “go shoot [themself]. I do not care.”
• Failing to quickly and properly suspend or fire the doctor despite multiple allegations of misconduct and abuse

According to the report:

Failure to follow VA and facility policy in response to incidents of employee misconduct and patient abuse undermines the public interest and continued risk to VA patients and staff…. The patient described not sleeping for four days following discontinuation of medicine, “terrible” appetite and concentration, and feelings of hopelessness and helplessness. The outpatient psychiatrist documented that the patient was “worried about going home and would feel suicidal if not admitted for detox.”

And yet the VA forced the veteran to leave, claiming he or she “didn’t meet the criteria for being admitted as an inpatient,” despite policies and protocols designed to protect veterans with suicidal thoughts.

A long history of bad choices and bad policies

The VA failed this veteran; we cannot know how many more were denied the care they needed, but it would not be surprising to find out there were more. Reporting by the Washington Post found that the Washington VA Medical Center was in the bottom 10% of all VA centers in 2019, and that last year’s IG report found:

• “Frequent turnover among facility executives. This contributed to the ‘the lack of evidence of ongoing, coordinated efforts to improve identified deficiencies, employee relations and patient care.’
• ‘Deficiency in staff education.’
• ‘1,550 inches of patient reports dating back to 2014.’ They ‘had not been scanned into the electronic health records,’ so patient information was not available to health-care providers. Stacking the records would reach the height of a 12-story building.
• ‘Deficiencies in infection prevention, environmental cleanliness, sterile supplies, medical equipment safety and mental health seclusion room safety.’”

Our veterans were willing to put their lives on the line to protect our freedoms. They deserve so much better than this.

Read More

• THE FAILURES OF THE D.C. VETERANS AFFAIRS HOSPITAL ARE PART OF A LARGER PROBLEM
• THOUSANDS OF VETERANS TURNED DOWN BY THE VA – AND THOUSANDS MORE ARE AT-RISK

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