Senators continue to ask questions about veteran safety following murders at VA hospital

West Virginia’s senators are still asking questions about responsibility and safety after a nursing assistant was sentenced in killing multiple patients at a West Virginia veterans hospital.

Former nursing assistant Reta Mays was sentenced last year to consecutive life terms for the deaths of eight veterans. Mays admitted causing their deaths by administering unnecessary and lethal doses of insulin while she worked the overnight shift. She had obtained the insulin from supplies at the hospital, although she was not supposed to possess it or administer it.

Joe Manchin

Senator Joe Manchin, D-W.Va., asked about steps taken by the VA to make sure hospital leaders are accountable for ensuring veterans will be safe. Manchin was participating in a hearing of the U.S. Senate Committee on Veterans Affairs called “Examining Quality of Care in VA and the Private Sector.”

The senator was revisiting questions about whether some top staff at the hospital appeared to transfer within the agency, rather than losing their jobs. Manchin addressed his comments to Carolyn M. Clancy, assistant under secretary for health for discovery, education and affiliate networks, veterans health administration for the Department of Veterans Affairs.

“We must make meaningful changes at the VA in West Virginia and across the country so that veterans in West Virginia and across the country can begin to rebuild their trust in the VA’s care,” Manchin said. He added, “We must hold those responsible for instances that place our veterans at risk accountable.”

Manchin cited “poor, inconsistent or ineffective leadership” at the time of the murders as an overriding factor. “It’s clear in the case of the Clarksburg VA, and yet individuals in position of leadership were able to simply resign and keep their valuable VA benefits, including retirement benefits.”

He asked, “How do we hold the VA leaders responsible in instances like the murders at Clarksburg? How do people stay in the system? How are they able to retire with benefits with such disrespect and neglect and malfeasance of doing their job.”

Clancy called the murders at Clarksburg a “horrific, horrific tragedy.”

“I can’t even imagine what it felt like to be told your loved one would be exhumed,” she said.

Manchin pressed again on whether the hospital leaders at the time were allowed to transfer elsewhere in the federal agency. He referred to legislation authorizing subpoenas such employees, putting them at risk of losing federal pensions.

“We have a whole new leadership team in there, as you know, as well as a number of new nursing leaders,” Clancy said.

Increased use of cameras in veterans healthcare facilities was a key recommendation of a 100-page probe of the deaths at Louis A. Johnson VA Medical Center in Clarksburg. The inspector general for Veterans Affairs concluded installation of cameras in sensitive areas of hospitals could suppress criminal behavior, one of several recommendations made through the probe.

Congress passed a bill last year meant to increase the use of video cameras for patient safety.

Shelley Moore Capito

Last week, Senator Shelley Moore Capito, R-W.Va., asked VA Secretary Denis McDonough for an update on the implementation of legislation to improve transparency and safety at VA hospitals through security cameras.

The law would require the VA to report to Congress on the use and maintenance of all cameras used for patient safety and law enforcement purposes in Veterans Affairs medical facilities. The report would include VA recommendations for improving and monitoring camera use throughout its healthcare system.

“Because of the things that happened at the Louis Johnson Veterans Facility, I was able, with the support of my colleagues, to ask the VA to install more cameras because that would have helped us a lot in trying to get the perpetrator a lot quicker than we did. And I think you have to report back by November the 23rd. I just wanted to put that on your radar screen to see if you had any comments on how that project is going and what kind of future you see,” Capito said.

Her question took place at a heading of the Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies.

McDonough described progress.

“So, it’s on my radar screen. Partly because of this hearing, partly because you and I talk on a very regular basis and I know how important it is you. We have deployed the cameras,” he responded.

“So we are beginning to use them and beginning to make these initial assessments. There is some privacy concern as you’re aware of that we’re working through, but we’ll be in a position to surely make that report to you in a timely way.”

Manchin also asked about the camera initiative during today’s hearing. “Do you find it to be helpful?”

Clancy said she would need to more thoroughly examine the additional steps involving cameras.

The former nursing assistant in Clarksburg pleaded guilty to killing veterans Robert KozulRobert Edge Sr.Archie EdgellGeorge Shaw, a patient identified only as W.A.H., Felix McDermott and Raymond Golden. She was 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’s Ward 3A 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.

The inspector general’s report underscored that Mays 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, giving her unauthorized access, the OIG report concluded.

Manchin today asked about VA hiring processes and whether the agency has made changes to review employee qualifications.

“As you say, a phone call almost certainly would have prevented this, which is unbearably painful to think about,” Clancy said, describing ongoing work to reform the hiring process.

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