Lapses in oversight allowed veterans to be killed by a night shift nursing aide at a West Virginia veterans hospital, a federal probe concluded, but the leaders who allowed those lapses haven’t been fired. Instead, they have been shifted to jobs in the U.S. Department of Veterans Affairs.
The VA announced last Christmas Eve that the hospital’s director, Glenn Snider Jr., would no longer serve in that role. Snider was reassigned and has been working at a regional office.
The medical center’s top executive for nursing was also reassigned to another job within the agency last Dec. 28.
Considering the permanent loss families continue to suffer after losing their loved ones under circumstances that could have been avoided, Senator Shelley Moore Capito, R-W.Va., said those who were responsible for patient safety shouldn’t just shuffle to new jobs.
“When you saw the failures in that report, it was quite stark,” Capito said on a call with reporters today.
“I don’t like the practice of the VA that you just pass the person who’s violating VA regulations and rules — and just pass them to the next job. To me, that’s a slap in the face to our veterans. So I think we need to really clean house at the VA. We’ve got families who are never going to have a loved one again. We have dead veterans here.”
Former nursing assistant Reta Mays was sentenced to multiple life terms this week for killing veterans Robert Kozul, Robert Edge Sr., 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.
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 admitted causing their deaths by administering unnecessary and lethal doses of insulin while she worked the overnight shift.
Concurrently with the sentencing, the inspector general for the Veterans Administration released a scathing 100-page report concluding that, although Mays killed the veterans, the hospital and its leaders were responsible for the conditions allowing her actions.
Veterans and their families entrust their lives every day at medical providers within the VA, wrote John D. Daigh Jr., assistant inspector general for healthcare inspections in an introduction to the federal report. They expect and deserve the highest quality of care in a safe and accountable healthcare setting, he wrote.
“However, the OIG found that the facility did not consistently promote a culture that prioritized patient safety as expected of a high-reliability organization. Consequently, a combination of clinical and administrative failures at the facility created the conditions that allowed Ms. Mays to commit these criminal acts and for them to go undetected for so long.
“Ultimately, the failure of leaders at multiple levels to ensure patient safety resulted in the tragic events described in this report.”
The inspector general’s report concluded that Mays’ earlier employment history meant she never should have been hired by the veterans hospital, which didn’t complete proper background checks. Allegations of excessive use of force were leveled against Mays while she worked as a corrections officer at the North Central Regional Jail.
And she also should not have had access to the insulin that caused fatal hypoglycemic episodes among the veterans. Medication rooms and carts were not properly secured on Ward 3 where Mays worked, the OIG report concluded, giving her unauthorized access.
Capito underscored those conclusions.
“The fact that there was no background check,” Capito said. “Availability of the insulin, so easily available in such large doses was startling as well. No check system.”
The OIG report noted that in every hospital, patients are exposed to risk. “Ultimately, quality health care is dependent on leaders who promote a culture of safety that reduces or eliminates those risks whenever possible,” the report stated.
When such a culture is sustained, the focus is on patients. Without that, systemic weaknesses can result in devastating consequences.
In Clarksburg, “the OIG found that the facility had serious, pervasive and deep-rooted clinical and administrative failures that contributed to Ms. Mays’ criminal actions not being identified and stopped earlier.”
The OIG report was particularly critical of the VA hospital’s associate chief of staff. After a flurry of deaths caused by hypoglycemia, a hospital employee realized with horror that “something was going on” — possibly criminal — and reported that to the associate chief.
The report notes that the associate chief’s initial response “exemplified the response of most employees — that the events were likely medically-based and there was no need to report.” The associate chief’s recommendation was to recommend more testing.
“Given the totality of events known to the associate chief of staff at the time,” according to the report, “the OIG found that the associate chief of staff’s initial reaction that additional testing was the appropriate response to this incident was concerning and not adequate.”
When reporters have asked whether Snider or others in supervisory roles should be fired, the Office of Inspector General has said that question lies outside its authority.
“Any type of personnel decision is really VA’s to make,” Michael Missal, the inspector general for the VA, told reporters this week.
In the roundtable interview with journalists covering the VA deaths, a Washington Post reporter observed “no one was fired.”
Missal responded, “Reta Mays was fired.”
The inspector general then followed up by saying again, “I think it’s really up to VA to talk about any type of personnel actions.”
Aside from Snider’s move to another job, the VA has acknowledged other personnel changes but with no specifics.
“Other personnel actions have occurred; however, due to privacy we are unable to provide those,” said Wesley Walls, spokesman for the Clarksburg VA hospital in response to MetroNews questions.
An archived version of the hospital’s leadership page shows that in October, 2020, Snider was the director, Terry Massey was the associate director, Pramoda Devabhaktuni was the chief of staff, and Paul Carter was the associate director for patient care services. Massey is now listed as the associate director of the VA St. Louis Health Care System.
The current leadership page for the hospital shows all those jobs are being filled on an interim basis.
A statement released by the Louis A. Johnson VA Medical Center this week pointed to several changes meant to assure patient safety.
“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 VA hospital stated.
Senator Joe Manchin, D-W.Va., said he would like greater assurance and more specific change. Manchin says he is meeting Monday with Denis McDonough, secretary of the U.S. Department of Veterans Affairs.
“I want to make sure he understands the need to absolutely overhaul the management and the practices of the VA hospital,” Manchin said this week.
Capito said she has not received enough assurance yet either.
“I don’t think the VA does a good job of wiping clean the slate when something bad happens at the VA,” she said. “This is a historic problem at the VA. And it seems to be repeating itself in Clarksburg.”