A Pattern of Problems at a Hospital for Veterans

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WASHINGTON -- In an unusually strong letter sent to the White House on Monday, the office that handles complaints from federal whistle-blowers says it has found a pattern of problems at a Department of Veterans Affairs medical center in Jackson, Miss., that raises serious questions about the hospital's management practices.

The problems over the last six years include poor sterilization procedures, chronic understaffing of the primary care unit and missed diagnoses by the radiology department.

Though some of the problems seem to have been addressed, the large number of whistle-blower complaints from one hospital -- five in this case, from separate people in different departments -- raise a "troubling pattern of disclosure," the letter from the Office of Special Counsel said.

"Collectively, these disclosures raise questions about the ability of this facility to care for the veterans it services," wrote Carolyn N. Lerner, the special counsel.

Some of the most serious problems are raised by a retired doctor who worked at the medical center for 30 years. He accuses the hospital of failing to notify patients whose X-rays and CT scans may not have been properly read by a radiologist.

That radiologist, who has left the hospital, was accused by colleagues in a lawsuit of missing diagnoses because he read images too fast or not at all.

"No efforts appear to have been made by the agency at any level to conduct a large-scale disclosure to the patients who were potentially affected by the radiologist's malfeasance," the special counsel says in a document provided to The New York Times. "It appears that the agency is also in violation of its own policy to ensure appropriate care."

In a statement, the Department of Veterans Affairs in Washington said that it was reviewing the letter and had opened investigations into the new whistle-blower complaints.

"G. V. (Sonny) Montgomery V.A. Medical Center takes seriously its commitment to providing quality care to our veterans," the statement said, referring to the Jackson hospital. "It is our goal to ensure veterans receive quality health care and we will continue efforts to improve our processes and services."

The Office of Special Counsel is authorized to receive complaints from executive branch employees about violations of law, mismanagement, misuse of funds or abuse of authority. Although it does not have investigative powers, it conducts in-depth interviews with whistle-blowers to determine whether their complaints meet a standard of "substantial likelihood."

When that standard is met, the counsel refers the case to the relevant agency, which then must conduct an investigation. Fewer than one in 10 complaints lead to such referrals, the counsel's office said.

The Jackson hospital, named after a Mississippi congressman who championed veterans issues, had been considered one of the better medical centers in the department's sprawling system of 150 hospitals.

But it has been troubled by recent investigations and a high level of turnover. Last year, the associate director for patient care services, Dorothy White-Taylor, was arrested on a charge of fraudulently obtaining the painkiller hydrocodone. Her case is still pending.

A few months later, the hospital's longtime chief of staff stepped down, and the Drug Enforcement Administration opened an investigation into whether nurse practitioners at the hospital were prescribing narcotics without proper licenses or adequate oversight by doctors.

The first of the whistle-blowers came to the Office of Special Counsel in 2009 accusing the hospital's sterilization department of having "routinely failed to properly clean and sterilize" equipment, including scalpels and bone cutters, documents show.

The veterans department's own investigation confirmed some of the accusations, including that the sterilization unit had sent instruments to the podiatry clinic that were "blood- and rust-stained and contained dirt and particles," according to special counsel.

Then in 2011, another former employee asserted that she had regularly observed workers in the sterile processing department not wearing required protective equipment like face masks and disposable gloves. That whistle-blower, Gloria Kelley, also said that employees in the unit did not receive adequate training. The Department of Veterans Affairs was unable to substantiate many of Ms. Kelley's accusations and the case has now been closed, Ms. Lerner said in her letter on Monday.

But Ms. Lerner sharply criticized the department's response, saying investigators never interviewed Ms. Kelley. "It does not appear that the agency has taken significant steps in improving the quality of management, staff training, or work product" within the sterilization department since the first accusations in 2009, Ms. Lerner wrote.

It is not clear whether anyone was sickened by faulty procedures in the sterilization unit.

The two most recent whistle-blowers raise potentially more serious issues. One, a doctor in the primary care unit, told the special counsel last year that nurse practitioners in her department were prescribing medications to patients even though the nurses did not have adequate licensing or oversight. The doctor, Phyllis Hollenbeck, also asserted that she and other doctors were pressured by superiors to sign prescriptions even if they had not seen the patients. Dr. Hollenbeck said she refused.

Dr. Hollenbeck also asserted that because of a lack of physicians in the primary care unit, nurse practitioners, including some who may not have had proper certification, cared for patients with little or no oversight.

The final whistle-blower, a retired ophthalmologist who was active in the physician's union at the medical center, told the special counsel that a former radiologist at the hospital "regularly marked patients' radiology images as 'read' when, in fact, he failed to properly review the images and at times failed to review them at all," the special counsel's letter to the White House says. In some cases, fatal diseases were not diagnosed, the letter says.

The accusations stem from a lawsuit in which female radiologists at the medical center claimed that the radiologist handled a large number of cases to increase his compensation, which was determined in part by productivity.

Although the radiologist denied wrongdoing, a jury found in the women's favor and awarded them unspecified damages in 2010. The doctor in question has since left the medical center.

But while changes in the radiology department have led to improved practices, the whistle-blower, Dr. Charles Sherwood, asserts that the medical center was obligated to notify all patients whose X-rays and CT scans might have been improperly reviewed to determine whether any problems were missed.

The department says it is now reviewing Dr. Sherwood and Dr. Hollenbeck's complaints.

It is unusual for the special counsel to publicly discuss accusations that have not been fully investigated by a federal agency. But the office made an exception in the case of Dr. Sherwood and Dr. Hollenbeck because their complaints seemed particularly serious and suggested systemic problems at the hospital, the special counsel's office said.

nation

This article originally appeared in The New York Times.


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