CLARKSBURG, W.Va. — The U.S. Department of Veterans Affairs has found multiple minor deficiencies with the Clarksburg VA medical facility’s pharmacy regarding tracking staff training as well as the handling of drugs.
The agency’s Office of Inspector General on Tuesday released a report related to allegations of inadequate training of new staff at the Louis A. Johnson VA Medical Center as well as noncompliance with recording controlled substances.
The report is not related to Reta Mays, a former nursing assistant who last month entered a guilty plea for the deaths of seven veterans.
While officials did not find anything supporting the claim that pharmacist orientation and training were poor, they did note pharmacy managers lacked tools to record annual pharmacist assessments and competencies.
“The OIG team’s review of pharmacy staff competency records also revealed that compounding pharmacy technicians, but not compounding pharmacists, had been tested in the written pharmaceutical calculations exam as required by facility policy,” the report noted.
“The Chief of Pharmacy confirmed that the intent of the policy was to ensure the compounding competency of pharmacy technicians but acknowledged that this was not specifically stated within the policy. As of January 6, 2020, all compounding pharmacists had passed the calculations exam.”
The Office of Inspector General also learned of an August 2018 incident in which pharmacy staff found three different substance bottles containing broken tablets. While the chief of pharmacy took appropriate actions, leaders did not send a required report to the U.S. Veterans Health Administration.
Investigators also learned of an instance when staff failed to added testosterone to inventory records and did not place the substance in a secure location.
The federal office issued three recommendations: track pharmacy staff assessments, ensure pharmacy staff understands current drug reporting requirements and develop an action plan to prevent future misplacements of testosterone.
U.S. Sen. Joe Manchin, D-W.Va., said the report is evidence the Clarksburg VA facility needs to undergo additional efforts to rebuild trust with veterans.
“While I commend the VA OIG for conducting this investigation after many concerned Veterans came forward, we must have a more in-depth examination of the leadership’s decisions and missteps that led to the murders of Veterans by Reta Mays,” he said. “Until we have full accountability and answers to our most basic questions about those deaths, I will not relent.”
Mays admitted to killing the veterans by injecting them with doses of insulin.