Reta Mays, now sentenced to life in prison as a serial killer, was hired out of a job fair.
Rejecting her hiring as an overnight nursing assistant was the first missed opportunity that cost the lives of at least eight veterans, probably more.
“You could say if they would never have hired her that this would never have happened,” Michael Missal, the inspector general for Veterans Affairs, said last week.
Mays was sentenced this past week to multiple life terms this week for killing veterans Robert Kozul, Robert Edge Sr., Archie Edgell, George Shaw, a patient identified in charges as W.A.H., Felix McDermott and Raymond Golden. She was also guilty of administering insulin to “R.R.P.,” another patient who was not diabetic, with intent to kill him. He later died.
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 as she sat at their bedsides.
A probe by the inspector general concluded that a botched background check should have prevented Mays from remaining on the job because of complaints that she had engaged in abusive behavior in a prior job as a corrections officer. Instead, she had access to vulnerable veterans on the overnight shift for years.
“If they had looked at it, maybe they would have never hired her in the first place,” Missal said.
Hiring without checks
Mays started work at the Louis A. Johnson VA Medical Center on June 28, 2015 after participating in a local hiring fair that included interviews by nursing leaders.
As a potential employee, Mays completed a questionnaire while human resources staff initiated requirements that included scrutiny such as fingerprints, a credit check and law enforcement, education and employment checks. She received a conditional offer, dependent on the results of the background check, and started at $32,000 a year.
Separately, supervisors at the VA hospital were recommended to conduct reference checks. But two human resources officers told the OIG that such checks were not required at the hospital in 2015.
The hospital had a position responsible for reviewing background checks and determining whether job candidates were suitable for employment. But the OIG found no documentation of such determinations, favorable or negative, by late 2015.
The employee who held that job left in 2018, and the replacement told federal investigators of finding “stacks” of inconclusive cases left in filing cabinets. The employee now holding the job told the investigation team of completing more than 150 backlogged cases.
‘How do you like that?’
Calls and questions could have revealed concerns about Mays that arose during her employment as a corrections officer at the North Central Regional Jail from 2005 to 2012, when she was the subject of excessive force allegations. And that could have prompted her dismissal at any time during her VA hospital probation period that concluded in September, 2016.
Mays was among corrections officers at the North Central Regional Jail accused in a 2013 federal lawsuit of threatening, intimidating and beating an inmate. The inmate’s handwritten complaint alleged Mays — listed now as 5-foot-2 and 230 pounds — “was holding his head, applying pressure to his axis” while another officer was “literally trying to break his right arm.”
Later, in the recreation yard, the inmate alleged he was pushed to the ground and that Mays was among corrections officers who kicked him.
The inmate described passing out and then regaining consciousness. The inmate then alleged Mays bent down, spit in his face and asked “How do you like that?” while calling him a profane name and saying “You ain’t that tough now, are you?”
A magistrate judge dismissed the claim in 2013, “for failure to state a claim upon which relief can be granted, as frivolous and malicious.”
After Mays left the job at the jail, she worked from October 2012 to July 2015 at a residential facility.
“The OIG did not find evidence that any hiring manager contacted Ms. Mays two most recent employers, including the jail, to verify employment data and make additional inquiries about skill and performance,” the inspector general’s investigators wrote.
Bottom line: “The conduct, if known, may have been disqualifying for Ms. Mays to retain a VA position in which she would be providing direct patient care.”
‘Successful, excellent and outstanding performance ratings’
The night shift job Mays landed at the VA hospital did not call for many skills and did not have many responsibilities. Representatives of the OIG last week weren’t clear on how motivated the VA hospital might have been just to find someone to fill the opening.
“These are very low-paying jobs and do require certain skills but certainly not at a very high level,” Missal said. “I don’t know if we ever were informed of what kind of candidate pool they had.”
The job meant Mays was supposed to be able to help patients with physical and behavioral problems under the direction of a registered nurse, talk with families and other personnel, and react to emerging situations such as recognizing the need for basic life support or controlling bleeding while calling for assistance.
“They are not capable of determining when a patient is suffering, what the natural course of their disease is,” said Julie Kroviak, deputy assistant inspector general for healthcare inspections. “She was never trained or capable of making those decisions.”
That includes administering insulin to patients who did not need it.
Mays received “fully successful, excellent and outstanding performance ratings” in October 2015, 2016 and 2017, the inspector general’s report noted. She served on nursing morale and scheduling workgroups.
There were some incidents that drew scrutiny, though. In one instance, Mays took the cap off a blood tube to access a blood sample, ostensibly to avoid subjecting the patient to another fingerstick. On another occasion, she left a patient in soiled bedding at the end of her shift. In both cases, she received verbal corrections.
“During interviews, some nursing colleagues told the OIG inspection team that Mrs. Mays exhibited odd or aggressive behavior toward patients at times, which they typically attributed to stress in Mrs. Mays’ personal life,” the report noted.
‘Award for Excellence,’ and a miss
Mays was recognized with an award for her performance, an instance that investigators now view as another missed opportunity to scrutinize her prior employment history.
In December 2016, just months after her hiring, the Ward 3A nurse manager at the time nominated Mays for the VA Secretary’s Award for Excellence, describing Mays as “a hard worker who had an excellent rapport with ward 3A’s healthcare team and who demonstrated a true compassion for veterans.”
Those awards require a completed security check, representing another chance to flag Mays. But the hospital staffer responsible for security checks again marked “favorable” even though there was no evidence such a check had ever been completed.
So, rather than additional scrutiny, Mays received the Secretary’s Award for Excellence/Nursing Assistant of the Year and $500. She also received cash awards in 2017 and 2018.
This point has drawn outrage from Senator Shelley Moore Capito, R-W.Va.
“The fact that there was no background check. The fact that she got employee of the year and they just checked the box and said ‘Yeah, she had a background check.’ Total lie,” Capito told reporters last week.
‘I felt such guilt’
Mays 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.
When patients like Army veteran Robert Kozul were admitted to the hospital, families were told they could take a break at night, rather than stay over and face exhaustion, because there was reliable overnight help.
“One of the things that stood out and haunts both of us is that when he was admitted on that floor they told us they had this wonderful sitter who would sit with him at night so we didn’t have to stay around the clock,” said Becky Kozul, Robert’s daughter-in-law.
“Now this sitter they hired murdered him.”
At the sentencing last week, Amanda Edgell described spending hours speaking with Mays while waiting and hoping for a full recovery for her father-in-law, Archie, an Army veteran who served in the Korean war. Archie had gone into the hospital to treat vascular dementia but died after a blood sugar crash.
Now the knowledge that she calmly sat with the night shift aide weighs on her.
“I feel such guilt that I didn’t know what was happening,” Amanda Edgell said in testimony at the sentencing.
Timeline of silent terror
At that sentencing hearing, Judge Thomas Kleeh went step-by-step through the spine-tingling steps of the nursing assistant’s silent rampage.
The first confirmed murder was Robert Edge Sr. on June 20, 2017. Then in August and September, investigators later discovered, Mays started bingeing a series on Netflix, “Nurses Who Kill.” Its description: “Top medical, criminal and psychological experts analyze the motives and methods of nurses who use their positions to kill rather than heal.”
In September, the judge said, Mays told a counselor she was afraid she would hurt someone in the moment. “You already had,” the judge told her.
Months went by. Robert Kozul, a smiling veteran who loved music and dancing, died on Jan. 30, 2018. Mays, the judge said, had stood by watching as treatment was delayed and then as staff tried to save him “from the hypoglycemic event that you caused.”
That March, the judge said, Mays told a registered nurse sitting with Edgell that she could go take a break. About that time, Mays complained about Edgell’s behavior. Edgell died after receiving unauthorized doses of insulin March 24 and 25. “This was no mercy killing,” Judge Kleeh said.
In April came a string of three deaths in three days.
William Alfred Holloway, a U.S. Army veteran of World War II, died April 8, 2018. The judge described an ominous message Mays had sent to a coworker: “I’m going to kill 34,” referencing his room number. The colleague interpreted the comment as blowing off steam in the workplace, said Missal, the inspector general — “more of a comment out of frustration than it seemed like she intended to kill anyone.”
Felix McDermott, an Army veteran who served in Vietnam, received a fatal dose of insulin and died April 9. Nurses ordered a review of whether someone had inadvertently administered insulin to the wrong patient.
Next was Shaw, an Air Force veteran who enjoyed bowling and gardening, who died April 10, 2018. Mays had repeatedly accessed his file before killing him, the judge said. “He was up and walking around before you took his life.”
It was around this period of death after death after death, the judge said, “that from your work computer you began Googling female serial killers.”
‘Something was going on’
The deaths weren’t finished.
On June 8, Army veteran Raymond Golden, who had served in Vietnam, died of unexplained hypoglycemia. He died, Judge Kleeh said, as the nursing aide “sat in Mr. Golden’s room while efforts to save him were made. Mays declared ‘something always happens and I don’t know why.'”
June 15 brought the death of Russell Posey, another World War II veteran. His last recorded interaction with a healthcare worker was with Reta Mays, who at 4 a.m. offered him breakfast and a bath. At 5:30 a.m. his blood sugar crashed to 14.
This was finally the moment, after all the deaths under similar circumstances, that someone at the hospital put words to the fatal problem.
An employee described in the OIG’s investigation as Hospitalist B had treated several of the veterans and knew of others. That employee sounded the alarm, but hospital supervisors at first recommended more testing to be sure. In retrospect, investigators found that reluctance to act “concerning and not adequate.”
But, inspectors wrote, “Hospitalist B insisted that ‘something was going on’ and that it was possibly criminal.”
An associate chief of staff notified the chief of quality and risk management. The next day, the facility director was notified while on scheduled leave.
On June 27, 2018, the director contacted the OIG’s Office of Investigations after-hours duty agent to request an investigation “with the belief that there was at least one criminal act, possibly more, committed.”
The following day, the Veterans Health Administration’s executive in charge informed Missal, the inspector general, that “there may be an Angel of Death in Clarksburg.
The federal investigation started that day.
‘She would not be caring for patients’
Inspectors were on site at the hospital starting July 2 and 3, a Monday and Tuesday.
On July 5, a Thursday and a week after the investigation was initiated, Reta Mays was identified as a person of interest. The OIG recommended to hospital leaders that she be removed from patient care. That same day, “she was assigned to a non-clerical position where she would not be caring for patients.”
There she remained, under suspicion but still employed, for the next nine months.
Finally, on March 6, 2019, after the deaths of at least eight veterans who had expected to live, Reta Mays was fired.
“When you find out more and more about this person after the fact, you’re like ‘How in the world did this even happen? How did this person even get employed knowing she didn’t have the correct credentials, knowing she didn’t have the background to be around these patients?'” Becky Kozul asked this week.
“Betrayal is the word we have used with the VA. We just felt betrayed by them.”