More than 120 previously unpublished investigations by the Veterans Affairs Department's inspector general, dating as far back as 2006, reveal problems at VA medical centers nationwide ranging from medical malpractice and patient safety concerns to mismanagement, infighting and corruption.
VA Assistant Inspector General John Daigh posted the reports on the VA inspector general's website in April after receiving criticism that his office failed to disclose results of an investigation into the Tomah Wisconsin VA Medical Center charging that a psychiatrist prescribed dangerous amounts of painkillers and other medications to patients, resulting in at least one death.
Daigh told lawmakers he did not "hide" the results of the Tomah investigation and explained that he routinely closes investigations for a variety of reasons — either the facility under investigation has taken steps to correct the issue, a lawsuit has been filed over an incident, or, in the case of Tomah, allegations were not substantiated.
But lawmakers say procedures that allow VA facilities to fix themselves after being investigated by the department's inspector general make no sense.
Pointing to scandals that have plagued VA in the past year, ranging from off-the-books appointment wait lists to construction overruns totaling more than $1 billion to whistleblower intimidation and more, House and Senate lawmakers continue to question VA's commitment to transparency.
Sen. Ron Johnson, R-Wis., subpoenaed the department last month for all documents related to the Tomah investigation. The same day, the House Veterans' Affairs Committee issued a subpoena for documents related to personnel at the Philadelphia VA.
"It is past time for the VA inspector general to be transparent and accountable and to show its work on its Tomah health care inspection," Johnson said. "I will continue to fight to get answers."
Of the reports released in April, 59 contained substantiated claims and made recommendations for VA facilities to address. Another 50 either did not validate allegations or resulted in litigation, prompting the inspector to close those cases.
The reports explore the petty — an anonymous complaint that a nurse put hot sauce on a patient's doughnut in Murfreesboro, Tennessee, which went unsubstantiated — to the tragic, including a veteran in San Diego who was prescribed an antacid at a VA emergency room and sent home but died of a heart attack the next day at a civilian hospital.
As with the Tomah report, several cases involve doctors overprescribing psychiatric medications or painkillers — an ongoing problem at VA that administrators say they are working to address.
At the Malcolm Randall VA Medical Center in Valdosta, Georgia, a doctor was accused of overprescribing psychotropic drugs to his female patients to the point that several lost their jobs.
The inspector general did not find any instances of veterans having lost employment, but did find that the doctor prescribed medications without performing required heart tests and failed to use current prescribing practices for mental health conditions.
In Tampa, Florida, a physician at the James A. Haley Veterans Hospital was counseled for more than two years by supervisors for prescribing controlled substances at rates "significantly higher than his peers."
The inspector general found that efforts to mentor the doctor "did not result in changes to his prescribing practices." But because the hospital was proactive in counseling the physician, the IG recommended only that supervisors also notify the Professional Standards Board and closed the case.
"While there was potential for harm to patients, we didn't find any patients that were harmed," the IG office wrote in the report.
Other reports ranged from poor practices to misrepresentation of credentials to doctor errors.
In Lebanon, Pennsylvania, a veteran who went into surgery to have a skin cancer removed from his nose had his face set on fire during a surgical mishap. (The same thing happened five years later to a patient at the Martinsburg, West Virginia, VA facility.)
In Birmingham, Alabama, and elsewhere, the inspector general investigated numerous cases of undiagnosed cancers, including one case of pharyngeal cancer that spread after the primary care doctor failed to place a referral to a specialist.
In Bay Pines, Florida, a veteran broke his leg at the hospital and it was not recognized or treated for a week.
At the VA Central Iowa Health Care System, a doctor conduct unauthorized research on patients — namely subjecting them to an extra radiological exam — without their consent or the approval of an independent board.
At the Hampton, Virginia, VA, the system for monitoring patients worked only intermittently for three years, allowing elderly patients with dementia to wander away from the facility.
In addition to patient safety and health problems, the reports unveiled an abundance of personnel problems, from a foreign medical student representing himself as a doctor and sexually harassing other employees at the Michael Debakey VA Medical Center in Houston, to a "toxic" work environment on the night shift at the intensive care unit among "cliques of nurses" in Tucson, Arizona.
In one case at the James Haley Medical Center in Tampa, the IG was called in to examine allegations that the spouse of a wounded patient on the ward had made outlandish demands, resulting in a poor work environment for staff and general unhappiness among other patients and their families.
According to the allegations, the spouse refused to allow anyone to enter her husband's room without permission, demanded one-on-one 24-hour care for her husband and asked that the floor, which had open visiting hours to encourage families and children to visit, be quiet from 4 p.m. and 6 p.m. so her husband could rest after an exhausting day of physical therapy.
The IG was called in after families threatened to go to the media with allegations that the patient received preferential treatment.
Not surprisingly, a handful of the allegations in that case were substantiated, including one verifying that a "slanderous allegation" was made about the veteran's wife, according to the IG report.
Daigh told lawmakers last month that his office produces 60 "hotline" reports a year and receives about 50,000 tips or calls annually. He added that all closed reports are made available to members of Congress or can be obtained through a Freedom of Information Act request.
But for lawmakers, these reassurances are not good enough.
Both the House and Senate Veterans' Affairs committees have stepped up their oversight of the VA and its IG office as a result of continued problems and have promised additional legislative measures to ensure the department complies with transparency and investigation laws.
'"VA Deputy Secretary Sloan Gibson recently said, 'I don't expect anybody to give that trust back, I expect we're going to have to earn it back,' If VA truly wants to be transparent and open, one of the first things it needs to do is to stop impeding this committee's oversight investigations," said House Veterans' Affairs Committee Chairman Rep. Jeff Miller, R-Fla.
Patricia Kime is a senior writer covering military and veterans health care, medicine and personnel issues.
