Soldier Is Told Paperwork Errors Will Slow Retirement
By Dana Priest and Anne Hull, Washington Post, Sept. 15, 2007
After nearly three years as an outpatient at Walter Reed Medical Center, Staff Sgt. John Daniel Shannon had begun the wrenching process of turning himself into a civilian.
He no longer wore the uniform he loved so much. He sported a short beard and traded his black beret for a baseball cap. Granted a 30-day leave to prepare for retirement as his disability case finally made it through the system, he moved his family to Suffolk, Va., and began to babysit his two kids, clean the house and grow vegetables. Given what had happened to him in Iraq -- the traumatic brain injury from an AK-47 round that shattered one eye and half his skull -- and the chronic post-traumatic stress disorder that followed, that was about all he could handle.
Last week, Shannon, 43, was back at Walter Reed, but not to say goodbye. The doctors' signatures on two time-sensitive forms in his disability file had expired. He would have to be reexamined by his doctors, he was told, and his medical summaries would have to be written all over again. Unfortunately, the sergeant in charge of his disability paperwork had not stayed on top of his case.
"There was a failure of paying attention to the currency of his paperwork," a Walter Reed spokesman, Charles Dasey, said last night.
The bottom line: No one could tell Shannon when he might go back to his family, transfer into the Veterans Affairs medical system and move on with his life.
After a Washington Post story in February described the conditions that Shannon and other wounded soldiers at Walter Reed endured after returning from Iraq, Shannon became something of a spokesman for his fellow patients.
He testified before a congressional hearing about the Army's obligation to care for its wounded. Members of Congress and generals shook Shannon's hand and thanked him for his courage, while President Bush and Defense Secretary Robert M. Gates promised swift changes. Three panels were set up to study not only Walter Reed's failures, but the entire overburdened military medical-care system for returning soldiers and Marines five years into war.
But none of that kept Shannon from getting caught up again in military bureaucracy.
"It's like being kicked in the teeth by a horse," Shannon said this week in a phone interview, alone in his room at Walter Reed. "I've been sitting here for three years. I don't even know what 'going on with my life' means. I want to scream at the top of my lungs. I'm at the end of my rope."
While Shannon, a senior sniper in Iraq, began speaking at public events and counseling other soldiers about the cumbersome Army disability process, he was quietly fighting his own battles.
The case manager assigned to shepherd him through the system was hard to reach. He couldn't get straight answers about his future. Appointments were still difficult to make. Finally, as his discharge seemed imminent, a cascading set of errors and inattention ensured the delay of his release. "It's been 33 months," he said. "What kind of beer are they drinking?"
After The Post's stories in February, the Army moved swiftly to fix the outpatient system. It created a new brigade structure to oversee the wounded and brought in combat infantry officers to run it. More platoon sergeants and case managers were added to give more individual service. Building 18, the moldy and mouse-ridden barracks for wounded outpatients, was closed, and soldiers moved into new living quarters with flat-panel TVs and computers.
But some soldiers still complain of lost paperwork and delays in appointments. In June, one dorm was without air conditioning. Up and down a sweltering hallway, soldiers used fans and kept their doorways open to ease the summer heat.
At a town hall meeting in July, soldiers vented their frustration over a variety of issues to Maj. Gen. Eric B. Schoomaker, Walter Reed's commander. One mother said that her son had been given discharge papers to sign with no explanation of his options. Other soldiers complained about an orthopedic surgeon, saying the doctor had been repeatedly "abusive and demeaning to patients" during the medical disability process and should be fired.
This week Shannon praised the new brigade; his company commander, Capt. Steven Gventer; and the medical and psychological care he has received. For Shannon and others, including some commanders, the disability process remains the largest source of anger. A presidential commission suggested doing away with the Army's long evaluation process -- which must essentially be redone by the Department of Veterans Affairs before any VA benefits can be calculated. But that has not happened.
In his time at Walter Reed, Shannon has had six different disability case managers assigned to him.
His latest round of bad news involved his current disability case manager. In August, the manager called Shannon in Suffolk to say that one important document was missing Shannon's signature. This would delay his retirement date.
Shannon was livid. It had been two months since his final surgery, and the process should have been close to completion.
"The files just sat there," he said. "When it got ready to go to the [evaluation] board, he noticed they weren't signed. Why was it so hard for him to do this job?"
The case manager informed Shannon that he himself was in the process of retiring and would be hard to reach, but he said he would fax Shannon the Army Form 3947 for his signature. The fax never arrived. Shannon said he could not reach the counselor, Sgt. 1st Class Allen Domingo, the next dozen times he tried.
Shannon and his wife were plunged into despair. Torry Shannon, who had spent two years caring for her husband and children at Walter Reed, had just started a house-cleaning business in Suffolk.
The delay and sense of neglect seemed an echo of their early days at Walter Reed, when Shannon, with a bandaged head from surgery and on heavy pain medications, was released from the hospital with nothing more than a map and told to find his room across post by himself. He had sat for weeks without appointments and without anyone to check on him. The family had almost gone broke. At one point they lived five to a tiny room.
Shannon, struggling with post-traumatic stress, was so angry that he broke things around the house, including his new Bluetooth earphone, which he smashed just thinking about all the new obstacles. His PTSD had been triggered, as it had been before, by the thought of soldiers treated disrespectfully. "It's about whether we're important enough," he said.
Last Friday, Domingo phoned Shannon with even worse news. Some of the doctors' signatures on some key paperwork -- narrative medical evaluations of his disabilities -- had expired. Shannon would have to make new appointments, get new signatures and be reevaluated.
Shannon checked back into a room at Walter Reed.
"I'm going to lose it. He's going to lose it," Torry Shannon said Tuesday morning. "He's cycling up again, and I've become a single parent in a 24-hour period. I just opened up a business. There's no one to watch the kids. . . . I want my husband home."
When Shannon tried to reach Domingo again for some explanation, the voice mail message told him what Domingo had not: "I will be out of the office from 10 to 14 September. I will be involved in transitional, retirement . . . training . . . please leave number and message. . . . Have a fine Army day."
Dasey, the Walter Reed spokesman, said Domingo was kept on the case for the sake of continuity. "Sergeant Domingo already has established a relationship with Sergeant Shannon," he said.
Domingo could not be reached for comment.
Dasey said Army officials determined last night that Shannon's paperwork is still valid and they would send his case on to the medical evaluation board, the last step in determining Army disability pay and benefits, on Monday. He said additional appointments with doctors would not be necessary. He could not explain how Domingo had made such a mistake.
Shannon said he would like to take over his case manager's job. He wants to make sure that other soldiers at Walter Reed, all younger and less outspoken, get the treatment they deserve. "I wish I could take his job so I could kick some doors in and say, 'Hey! What's going on here!' "
Showing posts with label va hospitals. Show all posts
Showing posts with label va hospitals. Show all posts
VA failing Mideast vets, lawsuit contends
Troops returning from Iraq and Afghanistan are not getting proper medical and mental health care, the suit says, citing post-traumatic stress disorder as a particular problem.
By Henry Weinstein, Los Angeles Times, July 24, 2007
SAN FRANCISCO — The U.S. Department of Veterans Affairs was accused in a major lawsuit Monday of "shameful failures" in providing medical and mental healthcare to injured servicemen and women returning from the wars in Iraq and Afghanistan.
The 73-page suit, filed in federal court here on behalf of hundreds of thousands of veterans, is the first of its kind and seeks to dramatically transform the way the VA operates.
The suit targets what it describes as the agency's "unconscionable" backlog of 600,000 claims, the adequacy of its services and the long waits to receive mental health care, particularly for post-traumatic stress disorder, which is described as the "signature problem" of vets returning from the current fighting.
A recent report by a special Pentagon task force found that 38% of soldiers and 50% of National Guard members coming home from Iraq or Afghanistan have mental health issues, ranging from stress disorder to brain injuries. But only 27 of the VA's 1,400 hospitals around the country have in-patient post-traumatic stress disorder programs, the plaintiffs' lawyers said.
The individuals suffering from post-traumatic stress disorder, or PTSD, are being deprived of mental health services in the early phases of the illness, when identification and treatment are critical, the suit alleges. Left untreated, severe PTSD can lead to substance abuse, depression and suicide, the lawyers said.
"A number of veterans have committed suicide shortly after having been turned away from VA facilities either because they were told they were ineligible or because the wait was too long," the lawsuit states.
In response to the suit, the VA issued a formal statement, saying it "is committed to meeting the special needs of our latest generation of heroes, and it would be inappropriate to comment directly upon a potential or pending lawsuit."
"Through outreach efforts, the VA ensures returning Global War on Terror service members have access to the widely recognized quality healthcare they have earned, including services such as prosthetics or mental health care. VA has also given priority handling to their monetary disability benefit claims."
Attorney Gordon P. Erspamer, one of the lead lawyers for the plaintiffs, said at a news conference that the lawsuit, which seeks class-action status, is an attempt to establish a basic set of "civil rights" for veterans.
"This isn't a case about isolated problems or the type of normal delays and administrative hassles we all occasionally experience with bureaucracies," said Erspamer, of San Francisco's Morrison & Foerster, which has taken the case pro bono. "This case is founded on the virtual meltdown of the VA's capacity to care for men and women who served their country bravely and honorably, were severely injured and are now being treated like second-class citizens."
"This is the first class-action lawsuit to directly challenge" the adequacy of care for post-traumatic stress disorder and "the VA's unconscionable backlog of claims," added attorney Sid Wolinsky of Disability Rights Advocates, a nonprofit advocacy group that also is representing the plaintiffs.
Symptoms of post-traumatic stress syndrome, the suit says, include intense anxiety, persistent nightmares, depression, uncontrollable anger and difficulties coping with work, family and social relationships.
Veterans suffering from PTSD and other psychiatric problems are less able to handle battles with the VA bureaucracy than other vets, according to retired Marine Col. James Cook, who spoke at the news conference. He brandished a 23-page standard form that veterans must fill out to seek help.
"The VA's outmoded systems for providing medical care and disability benefits" have been overwhelmed by "the huge influx of injured troops returning from Iraq and Afghanistan," the suit states. About 1.6 million men and women have served in the two countries since the Sept. 11, 2001, terrorist attacks.
The VA had significant problems even before the two current wars were launched, but its current backlog has become an "insurmountable barrier" that has made a mockery of the VA's mandate, said attorney Melissa Kasnitz, of Disability Rights Advocates.
"The VA's motto, taken from Abraham Lincoln's second inaugural address is, 'To care for him who shall have borne the battle and for his widow and orphan.' The VA is not living up to its motto or its obligation to care for our disabled veterans," she said.
The named plaintiffs are two veterans' advocacy groups, Veterans for Common Sense, based in Washington, D.C., and Veterans United for Truth, based in Santa Barbara. The case was not filed on behalf of individuals because "veterans fear retaliation," Erspamer said.
However, Paul Sullivan, executive director of Veterans for Common Sense, said that individual veterans would be speaking out in the future. "Since the Iraq and Afghanistan wars began, the VA has betrayed our veterans," said Sullivan, who served in the Army during the first Gulf War and worked as a project manager for the VA from 2000 to 2006, monitoring the disability claims of veterans from the Gulf War and the recent wars in Afghanistan and Iraq.
"Instead of hiring more doctors and claims processors," as he recommended, Sullivan said, "the VA instituted new policies that block veterans' access to prompt mental health care."
Sullivan is scheduled to testify Thursday at a hearing of the House Committee on Veterans Affairs, which will be considering a recently issued report by the Institute of Medicine examining how the VA handles treatment and compensation claims for PTSD.
The defendants in the lawsuit include R. James Nicholson, outgoing VA chief, several other ranking VA officials and Atty. Gen. Alberto R. Gonzales. A spokesman for the Justice Department said the agency would have no immediate comment because its lawyers were just beginning to review the suit.
The plaintiffs' lawyers emphasized that they were not seeking monetary damages. Rather, they said the suit was designed to stop repeated violations of federal laws that guarantee healthcare for returning veterans.
The plaintiffs' lawyers assert that the VA's claims-processing and appeal procedures for denied claims violate the veterans' constitutional rights to due process under the 5th Amendment and their right to petition for redress, guaranteed by the 1st Amendment.
Erspamer said the VA had created perverse incentives to deny claims by awarding employees bonuses based on the number of claims processed. Rather than considering veterans' claims carefully, he said it was much easier and faster to deny a claim, particularly a complicated one, than to grant it.
Moreover, the suit contends that the VA "has consistently presented misleading statistics" understating the length of time it takes to decide a claim, the number of veterans who need mental health services and the amount of money the agency needs to meet its obligations to veterans.
Sullivan said the two recent wars have generated more than 220,000 disability claims. The lawsuit also alleges that government officials have improperly persuaded many soldiers suffering from PTSD to accept "personality disorder" discharges by telling them they will get help faster. In fact, the suit states, agreeing to that bars veterans from obtaining disability benefits and from receiving ongoing medical treatment because the "disorder" is characterized as a "pre-existing condition."
Unless "systemic and drastic measures are instituted immediately, the costs to the veterans, their families and our nation will be incalculable, including broken families, a new generation of unemployed and homeless veterans, increases in drug abuse, increases in alcoholism and crushing burdens on the health care delivery system and other social services in our communities," the suit charges.
The attorneys said that although they were hoping for help from the federal court, congressional action also was needed to increase funding and other resources for the VA.
--------------------------------------------------------------------------------
henry.weinstein@latimes.com
By Henry Weinstein, Los Angeles Times, July 24, 2007
SAN FRANCISCO — The U.S. Department of Veterans Affairs was accused in a major lawsuit Monday of "shameful failures" in providing medical and mental healthcare to injured servicemen and women returning from the wars in Iraq and Afghanistan.
The 73-page suit, filed in federal court here on behalf of hundreds of thousands of veterans, is the first of its kind and seeks to dramatically transform the way the VA operates.
The suit targets what it describes as the agency's "unconscionable" backlog of 600,000 claims, the adequacy of its services and the long waits to receive mental health care, particularly for post-traumatic stress disorder, which is described as the "signature problem" of vets returning from the current fighting.
A recent report by a special Pentagon task force found that 38% of soldiers and 50% of National Guard members coming home from Iraq or Afghanistan have mental health issues, ranging from stress disorder to brain injuries. But only 27 of the VA's 1,400 hospitals around the country have in-patient post-traumatic stress disorder programs, the plaintiffs' lawyers said.
The individuals suffering from post-traumatic stress disorder, or PTSD, are being deprived of mental health services in the early phases of the illness, when identification and treatment are critical, the suit alleges. Left untreated, severe PTSD can lead to substance abuse, depression and suicide, the lawyers said.
"A number of veterans have committed suicide shortly after having been turned away from VA facilities either because they were told they were ineligible or because the wait was too long," the lawsuit states.
In response to the suit, the VA issued a formal statement, saying it "is committed to meeting the special needs of our latest generation of heroes, and it would be inappropriate to comment directly upon a potential or pending lawsuit."
"Through outreach efforts, the VA ensures returning Global War on Terror service members have access to the widely recognized quality healthcare they have earned, including services such as prosthetics or mental health care. VA has also given priority handling to their monetary disability benefit claims."
Attorney Gordon P. Erspamer, one of the lead lawyers for the plaintiffs, said at a news conference that the lawsuit, which seeks class-action status, is an attempt to establish a basic set of "civil rights" for veterans.
"This isn't a case about isolated problems or the type of normal delays and administrative hassles we all occasionally experience with bureaucracies," said Erspamer, of San Francisco's Morrison & Foerster, which has taken the case pro bono. "This case is founded on the virtual meltdown of the VA's capacity to care for men and women who served their country bravely and honorably, were severely injured and are now being treated like second-class citizens."
"This is the first class-action lawsuit to directly challenge" the adequacy of care for post-traumatic stress disorder and "the VA's unconscionable backlog of claims," added attorney Sid Wolinsky of Disability Rights Advocates, a nonprofit advocacy group that also is representing the plaintiffs.
Symptoms of post-traumatic stress syndrome, the suit says, include intense anxiety, persistent nightmares, depression, uncontrollable anger and difficulties coping with work, family and social relationships.
Veterans suffering from PTSD and other psychiatric problems are less able to handle battles with the VA bureaucracy than other vets, according to retired Marine Col. James Cook, who spoke at the news conference. He brandished a 23-page standard form that veterans must fill out to seek help.
"The VA's outmoded systems for providing medical care and disability benefits" have been overwhelmed by "the huge influx of injured troops returning from Iraq and Afghanistan," the suit states. About 1.6 million men and women have served in the two countries since the Sept. 11, 2001, terrorist attacks.
The VA had significant problems even before the two current wars were launched, but its current backlog has become an "insurmountable barrier" that has made a mockery of the VA's mandate, said attorney Melissa Kasnitz, of Disability Rights Advocates.
"The VA's motto, taken from Abraham Lincoln's second inaugural address is, 'To care for him who shall have borne the battle and for his widow and orphan.' The VA is not living up to its motto or its obligation to care for our disabled veterans," she said.
The named plaintiffs are two veterans' advocacy groups, Veterans for Common Sense, based in Washington, D.C., and Veterans United for Truth, based in Santa Barbara. The case was not filed on behalf of individuals because "veterans fear retaliation," Erspamer said.
However, Paul Sullivan, executive director of Veterans for Common Sense, said that individual veterans would be speaking out in the future. "Since the Iraq and Afghanistan wars began, the VA has betrayed our veterans," said Sullivan, who served in the Army during the first Gulf War and worked as a project manager for the VA from 2000 to 2006, monitoring the disability claims of veterans from the Gulf War and the recent wars in Afghanistan and Iraq.
"Instead of hiring more doctors and claims processors," as he recommended, Sullivan said, "the VA instituted new policies that block veterans' access to prompt mental health care."
Sullivan is scheduled to testify Thursday at a hearing of the House Committee on Veterans Affairs, which will be considering a recently issued report by the Institute of Medicine examining how the VA handles treatment and compensation claims for PTSD.
The defendants in the lawsuit include R. James Nicholson, outgoing VA chief, several other ranking VA officials and Atty. Gen. Alberto R. Gonzales. A spokesman for the Justice Department said the agency would have no immediate comment because its lawyers were just beginning to review the suit.
The plaintiffs' lawyers emphasized that they were not seeking monetary damages. Rather, they said the suit was designed to stop repeated violations of federal laws that guarantee healthcare for returning veterans.
The plaintiffs' lawyers assert that the VA's claims-processing and appeal procedures for denied claims violate the veterans' constitutional rights to due process under the 5th Amendment and their right to petition for redress, guaranteed by the 1st Amendment.
Erspamer said the VA had created perverse incentives to deny claims by awarding employees bonuses based on the number of claims processed. Rather than considering veterans' claims carefully, he said it was much easier and faster to deny a claim, particularly a complicated one, than to grant it.
Moreover, the suit contends that the VA "has consistently presented misleading statistics" understating the length of time it takes to decide a claim, the number of veterans who need mental health services and the amount of money the agency needs to meet its obligations to veterans.
Sullivan said the two recent wars have generated more than 220,000 disability claims. The lawsuit also alleges that government officials have improperly persuaded many soldiers suffering from PTSD to accept "personality disorder" discharges by telling them they will get help faster. In fact, the suit states, agreeing to that bars veterans from obtaining disability benefits and from receiving ongoing medical treatment because the "disorder" is characterized as a "pre-existing condition."
Unless "systemic and drastic measures are instituted immediately, the costs to the veterans, their families and our nation will be incalculable, including broken families, a new generation of unemployed and homeless veterans, increases in drug abuse, increases in alcoholism and crushing burdens on the health care delivery system and other social services in our communities," the suit charges.
The attorneys said that although they were hoping for help from the federal court, congressional action also was needed to increase funding and other resources for the VA.
--------------------------------------------------------------------------------
henry.weinstein@latimes.com
Seattle-area VA hospital criticized
By CURT WOODWARD, Associated Press Writer, AP, June 15, 2007
OLYMPIA, Wash. - The Department of Veterans Affairs knew for months that shower heads, handrails and other fixtures posed serious suicide risks to Seattle-area psychiatric patients, but refused to fix the problems, inspectors said in a report released Friday.
The VA said it scrambled to remedy problems in Seattle after a medical standards group threatened to pull its endorsement of two area hospitals last month. Health care for the nation's veterans has been rocked in recent months by accounts of shoddy treatment at the Department of Defense's Walter Reed Army Medical Center.
Sen. Patty Murray, D-Wash., was unsatisfied with the agency's response and personally inspected the Seattle VA hospital's progress on Friday.
"We are all clearly very, very concerned about the report that has come out," Murray told the administrators when she arrived at the hospital. "It set alarm bells off for all of us."
The Chicago-based Joint Commission, a nonprofit hospital standards group, said psychiatric ward conditions posed an "immediate threat to life" after it inspected the VA Puget Sound Health Care System in May.
VA officials initially refused to release details of the inspection, which was first reported by The News Tribune of Tacoma. Murray, a senior member of the Senate Veterans Affairs Committee, released it Friday after obtaining a copy.
The document said VA officials knew in February that suicidal patients could use several room fixtures to hang themselves, but "rejected that these were viable risks and elected not to correct." An internal report was issued that month after a patient at the Seattle VA hospital committed suicide in November.
The directors of the psychiatric wards at the hospital said they have been trying to weigh the threat posed by objects such as support bars on hospital bed against the fact that the fixtures are needed by patients.
After two hours touring the two psychiatric wards, Murray said the hospital is making progress on the issues identified in the commission's report.
Similar conditions were seen in a Tacoma psychiatric ward, but nothing was done — even though one patient tried to commit suicide in January, the report said.
Inspectors also said the procedure for determining psychiatric patients' safety was not up to par.
The Puget Sound VA started correcting the problems immediately in mid-May, when Joint Commission inspectors were visiting the hospitals, VA spokeswoman Jeri Rowe said.
"We started making changes within the first 24 hours they were here," she said of the four-day inspection.
Disclosures in February that war veterans were not getting adequate care at Walter Reed Army Medical Center stunned the public, outraged Capitol Hill and forced three high-level Pentagon officials to step down.
A group of senators moved Wednesday to boost disability pay to those hurt in combat and improve care for brain injury in response to shabby treatment of wounded soldiers at Walter Reed.
On Thursday, officials told The Associated Press that the Army is planning to hire at least 25 percent more psychiatrists, psychologists and social workers to help a growing number of soldiers with post-traumatic stress disorder and other mental health needs.
Walter Reed's new commanding officer said the Army medical system has lost the trust of soldiers, their relatives and the American people but is working hard to fix its problems and provide quality care to troops.
"We are working very hard to restore confidence and trust. We are very serious about this," Maj. Gen. Eric B. Schoomaker told the AP during an interview Friday in Jacksonville, Fla., where he planned to speak at the Florida Veterans of Foreign Wars Convention.
___
Associated Press writer Ron Word, in Jacksonville, Fla., contributed to this report.
OLYMPIA, Wash. - The Department of Veterans Affairs knew for months that shower heads, handrails and other fixtures posed serious suicide risks to Seattle-area psychiatric patients, but refused to fix the problems, inspectors said in a report released Friday.
The VA said it scrambled to remedy problems in Seattle after a medical standards group threatened to pull its endorsement of two area hospitals last month. Health care for the nation's veterans has been rocked in recent months by accounts of shoddy treatment at the Department of Defense's Walter Reed Army Medical Center.
Sen. Patty Murray, D-Wash., was unsatisfied with the agency's response and personally inspected the Seattle VA hospital's progress on Friday.
"We are all clearly very, very concerned about the report that has come out," Murray told the administrators when she arrived at the hospital. "It set alarm bells off for all of us."
The Chicago-based Joint Commission, a nonprofit hospital standards group, said psychiatric ward conditions posed an "immediate threat to life" after it inspected the VA Puget Sound Health Care System in May.
VA officials initially refused to release details of the inspection, which was first reported by The News Tribune of Tacoma. Murray, a senior member of the Senate Veterans Affairs Committee, released it Friday after obtaining a copy.
The document said VA officials knew in February that suicidal patients could use several room fixtures to hang themselves, but "rejected that these were viable risks and elected not to correct." An internal report was issued that month after a patient at the Seattle VA hospital committed suicide in November.
The directors of the psychiatric wards at the hospital said they have been trying to weigh the threat posed by objects such as support bars on hospital bed against the fact that the fixtures are needed by patients.
After two hours touring the two psychiatric wards, Murray said the hospital is making progress on the issues identified in the commission's report.
Similar conditions were seen in a Tacoma psychiatric ward, but nothing was done — even though one patient tried to commit suicide in January, the report said.
Inspectors also said the procedure for determining psychiatric patients' safety was not up to par.
The Puget Sound VA started correcting the problems immediately in mid-May, when Joint Commission inspectors were visiting the hospitals, VA spokeswoman Jeri Rowe said.
"We started making changes within the first 24 hours they were here," she said of the four-day inspection.
Disclosures in February that war veterans were not getting adequate care at Walter Reed Army Medical Center stunned the public, outraged Capitol Hill and forced three high-level Pentagon officials to step down.
A group of senators moved Wednesday to boost disability pay to those hurt in combat and improve care for brain injury in response to shabby treatment of wounded soldiers at Walter Reed.
On Thursday, officials told The Associated Press that the Army is planning to hire at least 25 percent more psychiatrists, psychologists and social workers to help a growing number of soldiers with post-traumatic stress disorder and other mental health needs.
Walter Reed's new commanding officer said the Army medical system has lost the trust of soldiers, their relatives and the American people but is working hard to fix its problems and provide quality care to troops.
"We are working very hard to restore confidence and trust. We are very serious about this," Maj. Gen. Eric B. Schoomaker told the AP during an interview Friday in Jacksonville, Fla., where he planned to speak at the Florida Veterans of Foreign Wars Convention.
___
Associated Press writer Ron Word, in Jacksonville, Fla., contributed to this report.
Bill to Block Funding for Navy's Outlying Landing Field (OLF) in Washington County, NC
Price, Butterfield Work to Block OLF
from NC Democratic Party, June 7, 2007
A key House committee today approved a bill that would block funding for the Navy's plan to locate an Outlying Landing Field (OLF) in Washington County, NC. The site has raised objections from the surrounding communities, environmentalists, sportsmen, and numerous state and local leaders.
Reps. David Price (NC-04) and G.K. Butterfield (NC-01) worked with their colleagues on the Military Construction Appropriations Subcommittee to strip the funding. Price is a member of the full Appropriations Committee and a former member of the military construction subcommittee. The bill, which passed the full committee by a voice vote today, is slated to move to the House floor within two weeks.
The funding prohibition follows House approval of a Defense Bill that would de-authorize the OLF project in Washington County. That bill is now working its way through the Senate.
"Today's action will allow us to cover all our bases as these two bills that impact the OLF move forward in Congress," Price said. "This should leave no room for doubt that we are serious about blocking any plans to locate a landing field next to the Pocosin National Wildlife Refuge."
"This is another clear, strong and simple message from Congress to the Navy about the need to choose a suitable location," Butterfield said. "Now it's time for the state and Navy work together and move forward."
Price and Butterfield also hailed the bill for fulfilling our nation's obligation to its servicemen and women, their families and our veterans. It provides the largest increase in funding for veterans health care in the VA's 77-year history, adding over 1,000 new claims processors to reduce the backlog of 400,000 benefits claims. It also increases funding to address the VA's repair and maintenance needs to prevent a Walter Reed type scandal from occurring in the VA system.
from NC Democratic Party, June 7, 2007
A key House committee today approved a bill that would block funding for the Navy's plan to locate an Outlying Landing Field (OLF) in Washington County, NC. The site has raised objections from the surrounding communities, environmentalists, sportsmen, and numerous state and local leaders.
Reps. David Price (NC-04) and G.K. Butterfield (NC-01) worked with their colleagues on the Military Construction Appropriations Subcommittee to strip the funding. Price is a member of the full Appropriations Committee and a former member of the military construction subcommittee. The bill, which passed the full committee by a voice vote today, is slated to move to the House floor within two weeks.
The funding prohibition follows House approval of a Defense Bill that would de-authorize the OLF project in Washington County. That bill is now working its way through the Senate.
"Today's action will allow us to cover all our bases as these two bills that impact the OLF move forward in Congress," Price said. "This should leave no room for doubt that we are serious about blocking any plans to locate a landing field next to the Pocosin National Wildlife Refuge."
"This is another clear, strong and simple message from Congress to the Navy about the need to choose a suitable location," Butterfield said. "Now it's time for the state and Navy work together and move forward."
Price and Butterfield also hailed the bill for fulfilling our nation's obligation to its servicemen and women, their families and our veterans. It provides the largest increase in funding for veterans health care in the VA's 77-year history, adding over 1,000 new claims processors to reduce the backlog of 400,000 benefits claims. It also increases funding to address the VA's repair and maintenance needs to prevent a Walter Reed type scandal from occurring in the VA system.
12 suspicious deaths reported at Salisbury VA Hospital
Congressmen grill VA execs about care
Lawmakers seek more info on revelations about Salisbury hospital
STELLA M. HOPKINS, PETER SMOLOWITZ & KAREN GARLOCH
Staff Writers
Charlotte.com posted on April 20, 2007
WASHINGTON --Lawmakers questioned VA officials Thursday about "serious inadequacies of care" at the Salisbury veterans hospital and demanded follow-up reports -- a strong signal they're not finished.
Federal investigators took too long to respond to a report of 12 suspicious deaths at the Salisbury VA, charged members of the House Veterans' Affairs Committee. They also complained that investigators didn't reveal findings of poor patient care and didn't verify the hospital made recommended improvements.
The 2005 investigation came six months after an anonymous complaint was referred to a VA team of inspectors.
"Come on, that's six months with 12 deaths," said California Democrat Bob Filner, the committee chairman. He directed that comment to Dr. John Daigh, who helps oversee VA health care inspections.
"We are talking about deaths of human beings -- people ought to be figuring out what is going on, do it fast and make corrections," Filner said.
Current and former leaders of the Salisbury hospital agreed there have been problems, but said they have been addressed.
"There were mistakes made, there were serious problems, and we think they have been corrected," said Dr. Sidney Steinberg, chief of staff at the Salisbury VA hospital who is also a surgeon who has been part of hospital management since 2001. He was the hospital's interim director until earlier this month, when the new director started.
Dr. Barbara Fleming, the VA's chief quality and performance officer, praised the Salisbury staff for a "phenomenal" turnaround. She said based on VA performance measures, the hospital is now among the top 25 percent of VA hospitals.
Committee members ordered VA officials to produce additional information, an investigation into patient care at the Asheville VA Medical Center.
Thursday's hearing, spurred by Observer articles over the past six weeks, was intended to bring tougher oversight to the nation's largest health care system. The Salisbury hospital is the main veterans medical center for the Charlotte area.
Investigation questioned
The VA is one of the largest federal agencies. Its 150 hospitals and 850 outpatient clinics nationwide are used by more than 5.5 million veterans a year who either can't afford private care or prefer a cheaper option.A key issue during Thursday's three-hour hearing: Last year, the VA closed its 2005 investigation without a second visit without a second visit, after the hospital said it made recommended changes.
At the hearing, VA officials gave their first public explanation of what they found after looking into the 12 deaths.
The Salisbury staff handled five cases correctly, according to a review by non-VA physicians. Five others were considered acceptable judgment calls. And in two cases, care was questionable.
The report from that investigation was not made public until the Observer obtained it last month. The newspaper also found that VA inspectors conducting a routine hospital inspection last year didn't know about the earlier report. The 2006 inspectors found more problems.
Chairman Filner said the two investigative teams should have known about each other's efforts, a lapse of coordination that he worries could be a systemwide problem.
In response to those concerns, the VA's Daigh told the Observer that last week he made sure his investigators have access to reports from other investigations.
"I made a mistake," Daigh testified. "We corrected the problem ...so we should not have the disconnect again."
The 2006 report found that a nurse had not properly monitored care for frail veterans the VA housed in private nursing homes. The report also said the nurse filed inaccurate patient reports, such as recording a patient in "stable" condition 12 days after he died.
The unnamed nurse has been disciplined and could be fired, according to a letter Wednesday from Daniel Hoffmann, regional VA director in Durham, to two N.C. congressmen, Republicans Howard Coble of Greensboro and Robin Hayes of Concord. The letter also said she is under investigation by the N.C. Board of Nursing.
"What the hell is she still doing there?" Filner asked.
Donald Moore, director of the Salisbury hospital from mid-2004 until last year, said he recommended firing her, but lawyers and human resources advised him that the nurse, who had an otherwise clean record for nearly 30 years, would likely prevail on appeal.
Thursday's hearing was requested by Hayes, Coble and Charlotte Democrat Mel Watt.
One committee member criticized a witness for focusing attention on buildings instead of patient care.
When Steinberg, the chief of staff, described the Salisbury hospital's new operating rooms and other capital improvements, Rep. Brian Bilbray, a California Republican, said:
"You can buy the most modern vehicle in the world, but if it's a reckless driver ...we're still going to have problems."
Stella M. Hopkins: 704-358-5173, shopkins@charlotteobserver.com; Peter Smolowitz: 704-358-5249, psmolowitz@charlotteobserver.com; Karen Garloch: 704-358-5078, kgarloch@charlotteobserver.com.
More Reports Sought
Several lawmakers asked for follow-up reports, including:
• Details of care for 12 patients who died and whose care the VA reviewed with outside medical experts.
• Details of contact, if any, with families of those patients who died. VA regulations require notification of care problems, but officials said Thursday that didn't happen in some cases reviewed at Salisbury.
• A report on what, if any, disciplinary action hospital officials took against doctors, nurses or other workers identified as providing poor care. Rep. Zachary Space, an Ohio Democrat on the investigative subcommittee, referred to "callous disregard by a bureaucracy" as he made the request.
• Bonuses paid to hospital management during the time they acknowledge problems. (The Observer requested this information earlier in the week.)
• A 2006 VA report on Salisbury under a systemwide internal quality review program.
Stella M. Hopkins
Sidebar:
Video Reporter Stella Hopkins on this issue
Archive Coverage of VA hospital issues
Timeline:
Aug. 30, 2004: Anonymous complaint to Office of Inspector General about more than 12 suspicious deaths at Salisbury veterans hospital over last two years.
June 9, 2005: Report from Office of Medical Inspector, after March inspection, finds care in certain surgical cases was "marginal at best, and in some cases, substandard."
Early March 2007: The Observer reported on that 2005 OMI report and a 2006 report by the Office of Inspector General, which found that a Salisbury VA nurse filed inaccurate reports on the health of veterans in nursing homes and listed one as being in "stable" condition 12 days after he had died. In a separate article, Donald Doering, former chief of nursing at Salisbury VA, said he was forced to step down in 2004 after urging top management to call a surgical "time out" to allow review of what might be causing unexpected deaths. The hospital has disputed Doering's account but provided no details.
March 21, 2007: Three N.C. members of Congress: U.S. Rep. Mel Watt, a Charlotte Democrat, and Republicans Howard Coble of Greensboro and Robin Hayes of Concord: urged the House Committee on Veterans' Affairs to hold hearings on Salisbury VA care.
April 1, 2007: The Observer reported on a 2001 survey by outside consultants, hired by the VA, which found sloppy patient records, poor tracking of drugs and IV solutions mixed in unsanitary areas. The hospital's infection rate had doubled in the previous year, the consultants said, but the hospital did not take "concrete actions to address this."
April 8, 2007: The Observer reported that the Joint Commission, a national accreditation organization, granted the Salisbury VA "accreditation with full standards compliance" in 2003, and renewed the accreditation in 2005, although it had no knowledge of the 2005 OMI report or that of the outside consultants.
April 15, 2007: The Observer reported that Dr. Paul Karmin, a former Salisbury VA radiologist, warned five years ago that pneumonia patients were at increased risk of dying because many weren't getting medicine promptly. VA officials said they have improved its pneumonia treatment times.
April 19, 2007: House Committee on Veterans' Affairs holding hearings on Salisbury VA care.
Lawmakers seek more info on revelations about Salisbury hospital
STELLA M. HOPKINS, PETER SMOLOWITZ & KAREN GARLOCH
Staff Writers
Charlotte.com posted on April 20, 2007
WASHINGTON --Lawmakers questioned VA officials Thursday about "serious inadequacies of care" at the Salisbury veterans hospital and demanded follow-up reports -- a strong signal they're not finished.
Federal investigators took too long to respond to a report of 12 suspicious deaths at the Salisbury VA, charged members of the House Veterans' Affairs Committee. They also complained that investigators didn't reveal findings of poor patient care and didn't verify the hospital made recommended improvements.
The 2005 investigation came six months after an anonymous complaint was referred to a VA team of inspectors.
"Come on, that's six months with 12 deaths," said California Democrat Bob Filner, the committee chairman. He directed that comment to Dr. John Daigh, who helps oversee VA health care inspections.
"We are talking about deaths of human beings -- people ought to be figuring out what is going on, do it fast and make corrections," Filner said.
Current and former leaders of the Salisbury hospital agreed there have been problems, but said they have been addressed.
"There were mistakes made, there were serious problems, and we think they have been corrected," said Dr. Sidney Steinberg, chief of staff at the Salisbury VA hospital who is also a surgeon who has been part of hospital management since 2001. He was the hospital's interim director until earlier this month, when the new director started.
Dr. Barbara Fleming, the VA's chief quality and performance officer, praised the Salisbury staff for a "phenomenal" turnaround. She said based on VA performance measures, the hospital is now among the top 25 percent of VA hospitals.
Committee members ordered VA officials to produce additional information, an investigation into patient care at the Asheville VA Medical Center.
Thursday's hearing, spurred by Observer articles over the past six weeks, was intended to bring tougher oversight to the nation's largest health care system. The Salisbury hospital is the main veterans medical center for the Charlotte area.
Investigation questioned
The VA is one of the largest federal agencies. Its 150 hospitals and 850 outpatient clinics nationwide are used by more than 5.5 million veterans a year who either can't afford private care or prefer a cheaper option.A key issue during Thursday's three-hour hearing: Last year, the VA closed its 2005 investigation without a second visit without a second visit, after the hospital said it made recommended changes.
At the hearing, VA officials gave their first public explanation of what they found after looking into the 12 deaths.
The Salisbury staff handled five cases correctly, according to a review by non-VA physicians. Five others were considered acceptable judgment calls. And in two cases, care was questionable.
The report from that investigation was not made public until the Observer obtained it last month. The newspaper also found that VA inspectors conducting a routine hospital inspection last year didn't know about the earlier report. The 2006 inspectors found more problems.
Chairman Filner said the two investigative teams should have known about each other's efforts, a lapse of coordination that he worries could be a systemwide problem.
In response to those concerns, the VA's Daigh told the Observer that last week he made sure his investigators have access to reports from other investigations.
"I made a mistake," Daigh testified. "We corrected the problem ...so we should not have the disconnect again."
The 2006 report found that a nurse had not properly monitored care for frail veterans the VA housed in private nursing homes. The report also said the nurse filed inaccurate patient reports, such as recording a patient in "stable" condition 12 days after he died.
The unnamed nurse has been disciplined and could be fired, according to a letter Wednesday from Daniel Hoffmann, regional VA director in Durham, to two N.C. congressmen, Republicans Howard Coble of Greensboro and Robin Hayes of Concord. The letter also said she is under investigation by the N.C. Board of Nursing.
"What the hell is she still doing there?" Filner asked.
Donald Moore, director of the Salisbury hospital from mid-2004 until last year, said he recommended firing her, but lawyers and human resources advised him that the nurse, who had an otherwise clean record for nearly 30 years, would likely prevail on appeal.
Thursday's hearing was requested by Hayes, Coble and Charlotte Democrat Mel Watt.
One committee member criticized a witness for focusing attention on buildings instead of patient care.
When Steinberg, the chief of staff, described the Salisbury hospital's new operating rooms and other capital improvements, Rep. Brian Bilbray, a California Republican, said:
"You can buy the most modern vehicle in the world, but if it's a reckless driver ...we're still going to have problems."
Stella M. Hopkins: 704-358-5173, shopkins@charlotteobserver.com; Peter Smolowitz: 704-358-5249, psmolowitz@charlotteobserver.com; Karen Garloch: 704-358-5078, kgarloch@charlotteobserver.com.
More Reports Sought
Several lawmakers asked for follow-up reports, including:
• Details of care for 12 patients who died and whose care the VA reviewed with outside medical experts.
• Details of contact, if any, with families of those patients who died. VA regulations require notification of care problems, but officials said Thursday that didn't happen in some cases reviewed at Salisbury.
• A report on what, if any, disciplinary action hospital officials took against doctors, nurses or other workers identified as providing poor care. Rep. Zachary Space, an Ohio Democrat on the investigative subcommittee, referred to "callous disregard by a bureaucracy" as he made the request.
• Bonuses paid to hospital management during the time they acknowledge problems. (The Observer requested this information earlier in the week.)
• A 2006 VA report on Salisbury under a systemwide internal quality review program.
Stella M. Hopkins
Sidebar:
Video Reporter Stella Hopkins on this issue
Archive Coverage of VA hospital issues
Timeline:
Aug. 30, 2004: Anonymous complaint to Office of Inspector General about more than 12 suspicious deaths at Salisbury veterans hospital over last two years.
June 9, 2005: Report from Office of Medical Inspector, after March inspection, finds care in certain surgical cases was "marginal at best, and in some cases, substandard."
Early March 2007: The Observer reported on that 2005 OMI report and a 2006 report by the Office of Inspector General, which found that a Salisbury VA nurse filed inaccurate reports on the health of veterans in nursing homes and listed one as being in "stable" condition 12 days after he had died. In a separate article, Donald Doering, former chief of nursing at Salisbury VA, said he was forced to step down in 2004 after urging top management to call a surgical "time out" to allow review of what might be causing unexpected deaths. The hospital has disputed Doering's account but provided no details.
March 21, 2007: Three N.C. members of Congress: U.S. Rep. Mel Watt, a Charlotte Democrat, and Republicans Howard Coble of Greensboro and Robin Hayes of Concord: urged the House Committee on Veterans' Affairs to hold hearings on Salisbury VA care.
April 1, 2007: The Observer reported on a 2001 survey by outside consultants, hired by the VA, which found sloppy patient records, poor tracking of drugs and IV solutions mixed in unsanitary areas. The hospital's infection rate had doubled in the previous year, the consultants said, but the hospital did not take "concrete actions to address this."
April 8, 2007: The Observer reported that the Joint Commission, a national accreditation organization, granted the Salisbury VA "accreditation with full standards compliance" in 2003, and renewed the accreditation in 2005, although it had no knowledge of the 2005 OMI report or that of the outside consultants.
April 15, 2007: The Observer reported that Dr. Paul Karmin, a former Salisbury VA radiologist, warned five years ago that pneumonia patients were at increased risk of dying because many weren't getting medicine promptly. VA officials said they have improved its pneumonia treatment times.
April 19, 2007: House Committee on Veterans' Affairs holding hearings on Salisbury VA care.
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