A criminal probe is underway into the Veterans Affairs Department’s handling of an outbreak of Legionnaires’ disease at the VA Pittsburgh Healthcare System.
The VA Inspector General has launched a criminal investigation separate from an administrative review completed in April that found the Pittsburgh facility did not adequately maintain its water systems to prevent Legionella propagation or flush hot water faucets routinely as recommended when the bacteria was detected.
From January 2011 to November 2012, at least 32 veterans contracted Legionnaires’ disease and five died, including William Nicklas, whose son Robert testified Monday before the House Veterans’ Affairs Committee during a field hearing in Pittsburgh.
Robert Nicklas said his father entered the VA hospital in Pittsburgh on Nov. 1 with symptoms of nausea; he died 22 days later of Legionnaires’, having been tested for the contagion just days before his death.
“Never was anyone in our family ever advised that there was an ongoing [Centers for Disease Control] investigation ... due to a Legionella outbreak at the hospital,” Nicklas said.
The House panel convened the hearing to determine whether VA management has taken steps to reduce preventable patient deaths and address patient safety concerns.
Panel members have charged that VA officials reward senior executives and physicians responsible at troubled medical centers with large performance pay incentives and bonuses instead of holding them accountable.
“Despite the fact that multiple VA inspector general reports have linked a number of these incidents to widespread mismanagement ... the department has consistently given executives who presided over these events glowing performance reviews and cash bonuses of up to $63,000,” said Rep. Jeff Miller, R-Fla., chairman of the veterans’ committee.
Family members and former hospital employees delivered heart-wrenching testimony on their loved ones’ treatment at the hands of VA, ranging from a once-vibrant 80-year-old left paralyzed by a botched surgery and ignored at a VA rehabilitation facility — to the point where he often sat for hours in his own feces — to a family who initially thought their veteran’s Legionairres’ infection was contracted at their own home, because that’s what VA doctors told them.
Lawmakers also heard from patients and whistleblowers from:
■ The Atlanta VA Medical Center, where three mental health patients died in 2011 and 2012, including a former Army paratrooper who killed himself in a hospital bathroom, and where the medical center director received $65,000 in performance pay.
■ The G.V. Sonny Montgomery VA Medical Center, Jackson, Miss., plagued by chronic understaffing as well as a criminal probe into improperly prescribed narcotics.
■ The Buffalo, N.Y., VA Medical Center, where officials revealed in January that more than 700 patients were exposed to infectious diseases when attendants reused insulin cartridges designed for single use. At least 18 veterans contracted hepatitis, while a hospital administrator received $26,000 in performance pay.
VA Undersecretary for Health Dr. Robert Petzel said he is deeply troubled by the experiences of the veterans and family members and said the incidents are not how VA prefers to conduct business.
He said VA has taken steps to learn from each incident. Improvements include new protocols at every VA health facility for single-use medical devices and responses to all VA inspector general recommendations for each medical facility.
The problems are serious, Petzel said, “but they are not systemic. VA has a long, sustained record of providing health care safely.”
He said he has sent the committee a full report on the disciplinary steps taken against executives in Pittsburgh and Atlanta and is reviewing departmental performance pay and award procedures.
Miller said committee members are reviewing the reports and pledged to continue hammering until Congress fesls VA has the “proper organizational culture, accountability and management structures” to minimize malpractice and preventable deaths.
“We are not here as part of a witch-hunt to make VA look bad or to score political points. We simply want to ensure that veterans across the country are receiving the care and benefits they have earned,” Miller said.