Denis McDonough, Secretary of the U.S. Department of Veterans Affairs, will be at the Louis A. Johnson Veterans Hospital in Clarksburg today where he will answer questions about the systemic procedural breakdowns at the hospital that allowed the murder of patients.
Reta Mays, a former overnight nurses’ aide at the hospital, admitted to murdering seven veterans and contributing to the death of an eighth by giving them doses of insulin that were not prescribed, triggering hypoglycemia. Civil suits attribute two additional deaths to her, and there may be more.
Mays acted alone, however, the VA’s Office of Inspector General’s detailed investigation released last week also places substantial blame on the hospital and individuals in supervisory positions.
Here are several of those key findings:
—“The OIG found that the facility did not consistently promote a culture that prioritized patient safety of a high-reliability organization. Consequently, a combination of clinical and administrative failures at the facility created the conditions [emphasis added] 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 [emphasis added] to ensure patient safety resulted in the tragic events described in this report.”
—“The OIG found that the facility had serious, pervasive and deep-rooted clinical and administrative failures [emphasis added] that contributed to Ms. Mays’ criminal actions not being identified and stopped earlier.”
So, who was responsible for these failures and how were they held accountable?
The Veterans Administration has largely stonewalled since the scandal became public, and when the agency does provide answers, they are vague.
Dr. Glenn Snider, the medical center Director at the time of the murders, was reassigned to another job within the VA. When asked about other leadership changes, the hospital’s response was, “Other personnel actions have occurred, however, due to privacy we are unable to provide those.”
The OIG report says the medical center’s former Associate Director of Patient Care Services, who is not identified in the report, was also reassigned to a different position within the Veterans Administration.
So, here is a question: Is anyone who was in a leadership position at the medical center during the murders who, according to the OIG report, failed to do their job going get fired? If not, why not?
The investigation strongly suggests if these individuals had been on the ball, Mays would have either not been hired in the first place or she would have been caught before the death toll rose.
West Virginia’s two U.S. Senators are pressing the VA for answers.
“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,” Senator Shelley Moore Capito said. “To me, that’s a slap in the face of veterans. So, I think we need to really clean house at the VA.”
Senator Joe Manchin is expected to take a similarly tough stand with the Secretary. “I want to make sure he understands the need to absolutely overhaul the management and practices at the VA hospital,” Manchin said.
The press will also have plenty of questions today. The breakdown at the hospital did not happen under McDonough’s watch–he was appointed by President Biden–but the responsibility for cleaning up the mess falls to him.
The hospital has made changes to ensure patient safety, and top leadership positions have been filled, at least on an interim basis, with a new team. Those are all much-needed steps to restore the kind of patient-first culture our veterans deserve.
However, the OIG report makes abundantly clear that the management failures under the previous administration contributed to the deaths of those veterans. Simply reassigning those responsible is barely a slap on the wrist, and is an insult to the families whose loved ones were murdered.