The chairman of the U.S. House Veterans Affairs’ Committee called for discipline for executives at Atlanta VA Medical Center in light of a report blaming three veterans’ deaths on pervasive mismanagement of mental health patients.
“Somebody in the VA System has to be held accountable,” U.S. Rep. Jeff Miller, R-Fla., said Tuesday. “And I don’t say that it stops at Atlanta. It needs to move right on up to Washington, D.C., the people within the system. If they can’t make the decision to discipline somebody, the Secretary needs to make it for them.”
Miller said he expects to visit the Decatur facility soon. He opened the possibility of holding a field hearing in Atlanta to examine how the hospital dealt with problems raised last week by the Inspector General for the Department of Veterans Affairs and the broader issue of veterans’ mental health.
“The biggest stick that we have to discipline the Department of Veterans Affairs with, unfortunately, is the dollar,” Miller said in an exclusive interview with The Atlanta Journal-Constitution and Channel 2 Action News. “And you don’t want to take money away from veterans, but we can sure shine a bright light — as we have with the disability claims as of late — on the failings of the Department of Veterans Affairs.”
A pair of audits focused on three recent deaths under the VA’s watch. One patient died of an apparent drug overdose after the DeKalb Community Service Board, which contracts with the VA, was unable to connect him with a psychiatrist for nearly a year after his referral. Another patient tried to see the VA facility’s Health Care for Homeless Veterans psychiatrist, who was unavailable, and the staff instructed him to take public transportation to the emergency department. He never went and committed suicide the next day.
At the inpatient mental health facility, the audit stated, patients were not watched closely enough. For two hours one afternoon staff members lost track of a suicidal patient who was supposed to be closely monitored, and he died that night of an overdose of drugs he got from a fellow patient.
The audit also found the waiting list for mental health treatment leapt from 53 to 397 from 2011 to 2012. A July 2011 audit had found similarly troublesome long waiting lists and managers who were too slow to take action to bring them down.
Atlanta-area members of the U.S. House, including Republican Reps. Phil Gingrey and Tom Price and Democrat David Scott, were preparing a letter Tuesday to VA Under Secretary of Health Robert Petzel seeking more information related to the audit.
“It is reprehensible that a federal audit was necessary to bring these tragic events to light, and we would like to seek assurances that nothing similar will happen in the future,” the members of Congress wrote, in a draft copy of the letter provided to the AJC. “In addition, we would like to know how the situation was allowed to get so out of hand before anything was done to rectify it.”
Miller said waiting lists for mental health care are a pervasive problem throughout the VA system, despite funding increases from Congress, and there is a lack of accountability for shortcomings. The VA did not dispute a word of the IG’s report. It is implementing a new patient tracking system and new policies on contraband and drug screenings, among other recommendations.
“The thing that concerns me with VA is when they find somebody who is not doing their job like they should, they don’t get rid of them. They just move them somewhere else,” Miller said. “Medical directors, chiefs of staff, they leave one facility and just go work at another. That doesn’t solve the problem.”
A spokesman for the Atlanta VA referred questions to a Washington counterpart, who did not respond directly when asked if anyone was disciplined because of the report or the deaths.
“VA recognizes the importance of providing national policy to all VA medical centers addressing hazardous items, visitation, urine drug screens and staff escorts for inpatient mental health programs,” VA spokesman Josh Taylor said. “VA will monitor the quality (of) mental health care and contract management to ensure that veterans receive the highest quality medical care from VA and its partners.”