Missing medications, improperly cleaned medical equipment and a doctor performing a procedure he didn’t have permission to do are among numerous problems recently discovered at the Atlanta VA Medical Center in Decatur.
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Troubles at Atlanta VA Medical Center
Inspectors from The Joint Commission, which accredits health care facilities, found numerous problems at the Atlanta VA Medical Center during a visit there in March. Those issues include the following:
- Missing medications
- Medical equipment not cleaned and stored properly
- Vague and incomplete treatment plans for patients
- Pharmacy storage areas covered in dust
- Natural gas spigots at the dental clinic not labeled correctly
- Doors not latching correctly
- No process for assessing whether doctors are competent to perform certain procedures
- Equipments and carts in the hallway restricting access to rooms
- Wires strapped to sprinkler piping
- Lacking process for disposal of hazardous medications
- Patient at risk for falls did not have a bracelet to alert staff of that risk
Mental health mismanagement
Two recent audits by the Inspector General of the U.S. Department of Veterans Affairs linked the deaths of three veterans over two years to rampant mismanagement of the mental health unit at the Atlanta VA Medical Center in Decatur.
Among the findings:
- From 2011 to 2012, the wait list for mental health treatment skyrocketed from 53 to 397 patients.
- Many of the 4,000 patients referred to outside mental health facilities “fell through the cracks.”
- Hospital staff lost track of a suicidal patient who was supposed to be closely monitored for two hours one afternoon. He died that night of an overdose of drugs he got from another patient.
- A schizophrenic man was missing for eight hours and told nurses “he got lost” on the way back to his room.
- Another patient with a history of substance abuse wandered the building for four hours, during which time he injected himself with testosterone.
- A patient who was referred to an outside facility died of an apparent drug overdose after the facility was unable to connect him with a psychiatrist for nearly a year after his referral.
- Another man was told by hospital staff to take public transportation to the emergency room after a VA psychiatrist was not available to see him. He never went and committed suicide the next day.