A federal probe has concluded that although former nursing aide Reta Mays bears ultimate responsibility for the murders of multiple veterans, missteps at the veterans hospital in Clarksburg opened the door to those tragedies.
“While responsibility for these criminal acts clearly lies with Ms. Mays, the OIG found inattention and missed opportunities at several junctures, which, if handled differently might have allowed earlier detection of Ms. Mays actions or possibly averted them altogether,” according to a report by the Office of Inspector General for Veterans Affairs.
Mays was sentenced to life in prison today in the deaths of eight veterans at the hospital in Clarksburg. Civil suits filed by families seek to hold the Department of Veterans Affairs responsible for even more deaths.
“How could something like this happen?” Michael Missal, inspector general for the VA, asked rhetorically today.
The report released today by the Office of Inspector General concludes that Mays’ earlier employment history meant she never should have been hired by the veterans hospital, which didn’t complete proper background checks.
And she also should not have had access to the insulin that caused fatal hypoglycemic episodes among the veterans.
“Our report found serious, pervasive and deep-rooted clinical and administrative deficiencies at the medical center,” Missal said. “It was a series of missed opportunities that contributed to the criminal actions occurring, not being stopped and for allowing it to go on as long as they did.”
Vows of change
Reacting to the inspector general’s report today, U.S. Senator Joe Manchin said he remains troubled that the veterans hospital in Clarksburg didn’t do enough to protect veterans.
“I just think there was an absolute lack of accountability, a total lack of accountability at Clarksburg VA,” Manchin, D-W.Va., said in a streaming press conference with reporters.
“The people that have been put in charge there should no longer be in the VA system as far as I’m concerned for the total disrespect they had for the well-being of our veterans. I think that shows up loud and clear in the OIG’s report.”
Manchin said he wasn’t able to discuss many details about the VA hospital until the investigation concluded.
“The shackles are off and I can guarantee you we’re going after them hard, very hard,” said Manchin, who is a member of the Senate’s Committee on Veterans’ Affairs.
The Louis A. Johnson VA Medical Center issued a statement today expressing grief over the loss of the veterans. The statement also expressed gratitude for the inspector general’s investigation , saying recommendations are being implemented and will be complete by March 2022.
“What happened at the Louis A. Johnson VA Medical Center was heartbreaking, and we want to ensure Veterans and families know we are determined to rebuild their trust,” stated Wesley Walls, spokesman for the VA hospital.
“While this matter involving an isolated employee does not represent the quality health care tens of thousands of North Central West Virginia Veterans have come to expect from our facility, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future.”
The actions of Reta Mays
Mays admitted to killing veterans by injecting with lethal doses of insulin while she worked the overnight shift. All had checked into the hospital to seek healthcare and all had expected to recover. None were being treated for diabetes, yet their blood sugar crashed under suspicious circumstances.
Mays, 46, of Harrison County, entered a guilty plea last July 14 to seven counts of murder and another count of assault with attempt to murder. Prosecutors said the last charge was because the victim lived for a period of time and Mays’ actions could not be determined to be the exact cause when the veteran died weeks later.
She admitted to killing veterans Robert Edge Sr., Robert Kozul, Archie Edgell, George Shaw, a patient identified only as W.A.H., Felix McDermott and Raymond Golden. She is also accused of administering insulin to “R.R.P.,” another patient who was not diabetic, with intent to kill him.
The charges and plea followed a two-year investigation that began after the VA Medical Center reported several suspicious deaths. Mays had access to the veterans’ hospital rooms. She wasn’t supposed to have access to insulin.
Never should have hired her
Mays began working at the Louis A Johnson VA Medical Center in Clarksburg in June 2015. She was removed from her job in July 2018.
She never should have been employed there in the first place, the inspector general’s report concluded.
“There was a failure to review Ms. May’s prior employment,” Missal said.
He alluded to allegations of excessive use of force against Mays during her employment at the North Central Regional Jail.
“Had VA, as required, gone back and looked at that employment they would have realized there were allegations of excessive use of force against her. The question is, with somebody with those kinds of allegations, should they be involved with patient care? That was one missed opportunity where they could not have hired her in the first place.”
Manchin called this the most egregious failing.
An award, and another miss
Instead, she worked the night shift, 7:30 p.m. to 8 a.m. in Ward 3A, which housed fragile patients who were not well enough to be discharged but whose conditions did not require the intensive care unit.
Her job as a nursing assistant required her to measure patients’ vital signs, test blood glucose levels and sit one-on-one with patients who required observation.
Prior to the horrifying revelations, Mays actually won an award for performing her duties — the Secretary’s Award for Excellence/Nursing Assistant of the Year on Sept. 12, 2017. It came with a $500 bonus.
But it also should have come with a completed security check. Instead, the OIG report found, a veterans hospital manager improperly stated that the background check had been favorable “in the absence of supporting information.”
“There’s yet another missed opportunity where if they’d looked at it they could have identified the issue.”
Access to insulin
Autopsies on exhumed bodies pointed to insulin injections that weren’t needed. The veterans died of low blood sugar level — severe hypoglycemia — caused by the insulin.
Medication rooms and carts were not properly secured on Ward 3 where Mays worked, the OIG report concluded, giving her unauthorized access to the insulin that was used to kill the veterans. The pharmacy service also did not have a formal process to track medications that could have been a tip about the cause of suspicious deaths.
“Everybody on Ward 3A, where Ms. Mays worked, had full access to the medication room and the medication cart,” Missal said. “This was a violation of policy, and they should have been secure.”
No diagnostic testing in deaths
Hospital personnel did not fully understand or pursue diagnostic testing for seven of the eight victims in the plea deal, the inspector general’s report noted, even though they were not diabetic and were n0t on diabetes medications.
“Hypoglycemia, particularly unexplained hypoglycemia is very rare,” Missal said. “They should have ordered some kind of diagnostic test to get to the bottom of what happened there.”
For the one person whose condition prompted a diagnostic test, “they actually ordered the wrong test,” Missal said.
Delayed response
There was delay in reporting and responding to the veterans’ blood sugar crashes even though concerns were being discussed internally, the OIG reported.
Missal called this “the failure of the hospitalists, the doctors and the nurses to communicate effectively about patient care.
“To have really high quality of care, you need to coordinate. As these events are occurring, they’re not talking to one another about how could this happen. Why is it on this ward? And why are we having such a rare event?”
A cluster of such events became apparent with four unexplained hypoglycemic crises in late March, early April and June, 2018.
“That should have set off major alarm bells. Some body should be asking the question and looking into it. They did not do so.”
Patient safety
Key quality and oversight controls didn’t measure up, the OIG concluded: “The facility did not consistently promote a culture that prioritized patient safety.”
Missal said a series of unexplained hypoglycemic events should have been reported to the patient safety department.
“None of them ever were.”
Some staff were not aware of what incidents to report and how to report them because they weren’t trained. “That’s a major failing of the medical center,” Missal said. “You put in place systems to prevent things like this, and it just wasn’t done.”
The veterans hospital today said those systems are being implemented: “During the OIG investigation, VA put in place safeguards to enhance patient safety, including medical chart audits, checks and balances within pharmacy quality assurance processes and quality management reviews.”
More actions needed
Officials took some corrective actions, the OIG noted, but much more needed to be done. That includes more effective mortality reviews, data analysis and examining the trends of adverse events for patients.
Missal said the hospital should have been able to use a mortality tracker that could have drawn attention to any spikes in deaths.
“During Ms. Mays’ time there, there were nine different times when there were mortality spikes. Nobody bothered to check. Nobody picked it up.”
Calls for changes
U.S. Senator Shelley Moore Capito, R-W.Va., said reading the inspector general’s report was “devastating.”
“The failures at the Clarksburg VAMC outlined within this report are absolutely unacceptable,” she said. “The findings show a collapse of administrative and clinical responsibility that has led to unimaginable consequences, which makes it clear that updated policy and procedure is desperately needed.”
Capito said more work remains to assure veterans feel safe and confident in their care while also holding those in leadership and positions of trust accountable. She said steps must be taken to ensure such tragedies are not allowed to happen again.
“Our veterans in West Virginia deserve the highest level of care possible, but they also need to be able to trust that they will be safe and protected under the care at our VAMC facilities,” Capito stated.
Congressman David McKinley, a Republican who represents West Virginia’s northern counties, said the VA report needs to be heeded to improve conditions and transparency.
“Our veterans have sacrificed so much for our country, and too often the VA has let them down,” McKinley said. “They deserve better. We will continue to work to reform the VA and provide oversight, so our veterans have piece of mind every time they go to a VA facility.”
Congressman Alex Mooney, a Republican who represents counties in the state’s middle district, said Mays was rightfully sentenced and that veterans should be assured their well-being.
“Those who served our nation in the military deserve not only our utmost respect, but also our well-being,” Mooney stated.
Congresswoman Carol Miller, a Republican who represents the southern counties in West Virginia, said veterans earned the best care possible and that anyone who violates that deserves the full force of the law.
“I am committed to providing the congressional oversight needed to ensure what happened at the Louis A. Johnson VA Medical Center never happens again,” Miller stated.