Another patient wandered the 26-acre campus for hours, picking up his prescriptions from an outpatient pharmacy and injecting himself with testosterone before returning voluntarily to his room.
The cases at the Atlanta VA Medical Center are the latest in a string of problems at Veterans Affairs facilities nationwide, prompting outrage from elected officials and congressional scrutiny of what is the largest integrated health care system in the country with almost 300,000 employees.
“It’s not just Atlanta. There are issues throughout the United States,” said Rep. Jeff Miller (R-Fla.), chair of the House Committee on Veterans’ Affairs, who noted there are many hard-working employees within the VA but feels legislation is needed to reform operations nationwide.
In recent years, there have been inquiries into the Pittsburgh VA system after five people died of Legionnaire’s disease and the Buffalo, N.Y., VA hospital, where at least 18 veterans have tested positive for hepatitis. There have also been whistleblower complaints ranging from improper sterilization procedures to radiology tests left unread at a VA facility in Jackson, Miss.
Meanwhile, the need continues to grow: In just the area of mental health, an estimated 13 percent to 20 percent of the 2.6 million service members deployed to Iraq and Afghanistan have symptoms of post-traumatic stress disorder. In fiscal year 2011, the VA served nearly 6.1 million patients at its 152 medical centers.
At the Atlanta VA Medical Center, two reports issued in mid-April by the Department of Veterans Affairs’ Office of Inspector General detailed allegations of mismanagement and poor patient care linked to three deaths. The case of a fourth veteran was a turning point for Miller: A man in a wheelchair came to the Atlanta VA emergency room complaining of hearing voices but was not admitted and later found in a locked hospital bathroom dead of an apparent suicide.
Officials at the Atlanta VA Medical Center said they had already taken steps to address the issues cited in the reports, which included requiring visitors to be supervised and closer patient monitoring. The facility serves some 87,000 veterans with an operating budget of more $500 million.
The interim director has been replaced, and a former deputy assistant secretary, Leslie B. Wiggins, has been brought in to take over.
“One of my primary goals is to ensure Atlanta has an environment that fosters physical and psychological safety,” Wiggins said during a May 20 news conference.
Rep. David Scott, a Georgia Democrat whose district is served by the center, met with Wiggins and said he was impressed with her experience and hopeful changes would be made.
“This is your own inspector general coming out and clearly pointing out these things. We have four soldiers, veterans who are dead because of actions taken by or lack of actions taken by the management at that hospital,” Scott said.
In one report, investigators found the Atlanta facility did not sufficiently address patient care safety, failed to monitor patients and did not have adequate policies for dealing with contraband, visitation and drug tests. In the case of the man who overdosed on drugs from a hospital visitor, the report said the man was searched when he returned to his room and given a drug test. However, it was later determined another patient had provided the urine. Investigators said the facility had not provided staff with a policy for collecting urine, which should include securing the bathroom or direct observation. Investigators also noted the unit had no written policy on patient visitors.
The report, which noted high patient satisfaction rates at the Atlanta facility, recommended the VA establish national policies addressing contraband, visitation, urine testing and escorts for inpatients of mental health units. The VA agreed and plans to implement those policies by Sept. 30.
A separate report linked two additional deaths to the facility and its referral program to outside mental health providers. Investigators noted the Atlanta VA Medical Center had referred more than 4,000 patients since 2010 but did not know the status of those patients.
“There is no case management or follow-up,” said one unidentified staff member quoted in the April 17 report.
One patient who died had a long history of mental health issues including suicidal behavior. He was evaluated and prescribed medicine for depression. A follow-up appointment was scheduled for four weeks later, and the patient committed suicide during that time, according to the report.
Miller has drafted legislation would address mental health care within the VA system. It would require the VA to contract with civilian contractors for mental health care while also requiring the VA to keep closer tabs on patients after receiving care.
Veterans interviewed at the Atlanta facility on a recent afternoon defended the level of care being provided.
“I’ve had good treatment here and good care,” said Lester Paulus, a 73-year-old retired Navy veteran from Canton, Ga., who received eye surgery and successful cancer treatment.