JACKSON, Miss. — The Veterans Affairs Medical Center in Jackson, Mississippi, is deficient both in providing appropriate patient care and in responding to identified problems, according to a letter sent yesterday to President Obama from Special Counsel Carolyn Lerner. The letter is a statutorily mandated report on the status of disclosures from two physicians at the Medical Center, a current primary care doctor and a retired ophthalmologist with knowledge of radiology issues.
The whistleblowers referenced in the letter are the fourth and fifth of seven Jackson VA employees in four years to disclose wrongdoing to the Office of Special Counsel (OSC). Past disclosures include the use of dirty, rust-stained instruments and other unsterilized medical equipment, incorrect sterilization procedures in the Medical Center and inaccurate statements to the public and Congress about problems at the Medical Center.
Allegations referenced include the following:
• Nurse practitioners lacking required licensure to prescribe narcotics in violation of state and/or federal law. Once the DEA discovered this and disallowed it, the VA pressured physicians to approve all nurse practitioners’ prescriptions without evaluating the patient in question. The VA confirmed these allegations and said reform is underway.
• Chronic understaffing in the Primary Care Unit threatens patient safety. The VA substantiated the understaffing but refuted any impact on patient care.
• Due to staffing shortages, nurse practitioners lack state-required supervision by a physician. The VA confirmed that this was true for some nurse practitioners and said reform is proceeding.
• A radiologist failed to read thousands of images or misread them, leading to missed diagnoses. Medical records were falsified to cover up these errors. Management knew of these problems and did not notify patients or require a full review of the images in question. While the VA conceded that the peer review process was substandard, it did not substantiate the allegations, citing reviews of a very small fraction of the thousands of images in question.
The letter also noted that in the midst of the agency’s own investigation into these practices, the director of the Jackson VA publicly stated that “the findings did not impact patient care,” despite the agency’s own admission that the impact to patients can be determined only through additional investigation.
“The agency’s response to these and other cases is inadequate,” said Special Counsel Carolyn Lerner. “In an era of thousands of returning service members, it is crucial that the VA provide appropriate care to veterans.”
OSC requested an update from the VA within 60 days.