OIG SAR 2001-2002

The uncle of a VA supervisory pharmacist was sentenced for his role as a co-conspirator with the pharmacist in the distribution of diverted drugs taken from a VAMC. The subject was sentenced to 70 months’ incarceration and 3 years’ supervised release, and was ordered to pay $4,140 in restitution. The subject’s role was to act as a go between, allowing the drugs to be distributed on the street. The investigation disclosed that over 233,000 dosage units of Schedule II and III narcotics were diverted from the VA pharmacy. The Drug Enforcement Administration and VA OIG jointly conducted the investigation. The pharmacist is to be sentenced at a later date.

Survey Results Employee Surveys

Employee feedback was obtained by mailing questionnaires to clinical employees of 11 VA facilities between May and September 2001.Completion of the questionnaires was optional, and employees' responses were anonymous. During this period, we mailed 3,722 surveys and received1,766 anonymous responses. This represents a 47percent response rate. Since we began performing CAP reviews, we have asked for employees' perceptions on a wide range of issues. We believe the resulting data can provide an independent, objective indicator of employee satisfaction for facility management to use in decision-making. Employees generally felt supported in their efforts to provide quality patient care; however, they perceived that additional emphasis is needed to ensure positive employee morale. Eighty-three percent of the respondents believed the quality of care at their respective facilities was either good, very good, or excellent. Seventy-three percent indicated they would recommend treatment to family members or friends. Fifty-two percent indicated staffing was not sufficient to provide adequate care to all patients. Feedback included concerns for the safety of patients and staff, as well as the assertion that it was not possible to deliver comprehensive care without sufficient nursing and specialty resources. Although 87 percent of employees reported they were generally comfortable in self-reporting errors that involved patient care, only 72 percent indicated they were comfortable reporting errors that involved colleagues. Furthermore, only 56 percent believed that constructive actions were taken when errors were reported. The results of the surveys received after each CAP were shared with managers at that facility.

A VAMC pharmacist was arrested for theft of VAMC non-controlled drugs. A joint investigation with VA police revealed the pharmacist was stealing a large volume of drugs from the VAMC pharmacy. He then sold the drugs through his own pharmacy, or to a co-conspirator who owned a pharmaceutical distributorship. Prior to the arrest, the VAMC pharmacy was placed under video surveillance and all high dollar drugs were marked with invisible ultraviolet ink. The video surveillance revealed the pharmacist stole VAMC drugs everyday that he worked. The search warrant served on the pharmacist's store as well as a consent search of the distributorship resulted in the recovery of a large volume of marked drugs valued at approximately $11,000. The monetary loss to VA is expected to exceed $350,000. A former VAMC pharmacist pled guilty to two counts of theft and was sentenced to 2 years' probation, ordered to avoid contact with the VAMC pharmacy, and to continue in a drug treatment program. A joint investigation with VA police revealed that over a 6-month period the pharmacist, who suffered from pain and depression, would search packages to be shipped to patients. When he located packages containing Vicodin, Percocet, or Ritalin, he would remove some or all of the drugs for personal use. A former VAMC pharmacy employee was arrested on charges that he aided in an armed robbery of a VAMC pharmacy. The former employee, a co-op student, was charged in a two-count criminal complaint with aiding and abetting a robbery in which controlled substances were taken, and with aiding and abetting the possession of a firearm in connection with the robbery. The former employee provided information and assistance to the individuals who carried out the crime. The robbery resulted in the theft of 3,000tablets of OxyContin, as well as varying amounts of other narcotic drugs. Street value of the stolen drugs was estimated at over $250,000. This case was investigated jointly with the FBI and VA police. A former VAMC maintenance supervisor, pleaded guilty to two counts of rape. The individual had been previously charged and arrested for participating in the rapes of individual she rendered unconscious with drugs stolen from VA. A joint investigation by the VA OIG, FBI, and VA police revealed the individual drugged the victims and videotaped the offenses. This arrest follows his previous convictions on two counts of manufacturing child pornography and one count of theft of Government property. A former VAMC nurse was ordered to pay a fine of $1,000 after pleading guilty to one count of information charging him with possession of a controlled substance. A joint investigation by the VA OIG, VA police, and U.S. Drug Enforcement Administration determined that between 1997 and1999 the nurse had diverted controlled substances from the VAMC intensive care unit by means of theft and falsifying documents. He then used the drugs for his personal use. Investigation disclosed that during his last year of employment, he was able to divert 6,600 milligrams of morphine, 15,000milligrams of Demerol, 95 Percocet tablets, and100 milligrams of Ativan. A former VAMC nurse pleaded guilty to a four count criminal information charging her with stealing various narcotics, including OxyContin and morphine, and converting them to her own use. This joint investigation by the VA OIG, FDA, and VA police determined the nurse stole liquid morphine from syringes and replaced the drug with saline solution. In addition, on at least 21 occasions she falsified medical records by stating she had administered various controlled substances to patients when in fact she had never administered the drugs and diverted them for her own use. As part of a plea agreement, she agreed to relinquish her nursing license and serve 6 months' incarceration.

Abuse of Veterans by Caregivers A grand jury indicted a VA psychiatrist for sexual assault. The indictment resulted from a joint investigation conducted by the VA OIG, VA police, and a local police department sex crimes division. The VA psychiatrist is accused of sexually assaulting a patient under his care at a VA outpatient clinic. Pending the outcome of the investigation and prosecution, the psychiatrist was removed from patient care.

Issue: Contract nursing home placement and follow up coordination. Conclusion: Standard of care was not met and a patient was lost to VA clinical oversight. Impact: Pending legal actions and enhanced coordination between VA facilities.

Senator Christopher Bond's staff asked us to review an allegation that a patient discharged from the VAMC and placed in a contract nursing home did not receive adequate care at the contract facility. At the time of discharge to the contract nursing home, the patient was clinically stable and agreeable to the placement. However, VA clinical managers concluded that the standard of care wasn't met at the contract nursing home because of lapses in documentation about the patient's condition, and the excessive time it took to provide the patient with urgent medical care. We agreed with the VA facility's findings. The family subsequently chose to pursue legal action against the contract nursing home. In addition, the VA voided the community nursing home national contract. We also noted that because of the distance between the originating VA facility and the contract nursing home, the patient's follow up should have become the responsibility of a VA facility nearer to the site. However, requisite communication between social work service employees at the VA facility out-placing the patient and VA facility nearer to the contract nursing home never occurred, and the patient was lost to VA clinical oversight. The originating medical center's Director acted to improve discharge planning and placement procedures at the VA facility, and coordination and follow up efforts among area medical centers. (Allegation of Wrongful Death in a VA Community Contract Nursing Home, 01-00787-81, 6/1/01)Issue: Patient abuse. Conclusion: Managers' inaction contributed to the loss of medical evidence needed to determine whether the patient was abused. Impact: Strengthened procedures and controls to improve patient safety. The Chairman of the Senate Committee on Veterans' Affairs and the VHA Office of Medical Inspector asked that we review an allegation that a patient was abused while he was hospitalized at a VA facility in 1998. The patient asserted that an employee hit him in the eye resulting in permanent lost of sight in his left eye. We found that: (i) the patient sustained an injury to his left eye after his admission to the VA facility, leading to the inability to see out of his eye; (ii) the Director should have, but did not conduct an administrative investigation of the issue at the time of the injury; and (iii) the patient and family were not informed of available options for possible compensatory damages as required by VHA policy. Managers' inaction contributed to the loss of medical evidence needed to investigate the case adequately.

Issue: Research improprieties.

Conclusion: Original consent forms were not in patients' medical records.

Impact: Strengthened research consent policy and improved quality. Complainants alleged that the Chief, Research Section: (i) conducted research on patients without appropriately notifying the health care team of the protocol and did not place informed consents in the medical records; (ii) did not use sound clinical judgment in the treatment of six patients; and (iii) discontinued grand rounds and omitted home care staff from discharge planning rounds. We did not confirm that the chief failed to use sound clinical judgment in treating the six patients. However, we substantiated that the chief had discontinued rounds and omitted home care employees from discharge planning rounds. We also noted that original consent forms were not always in the patients' medical records. The Director concurred with our recommendations and provided acceptable implementation plans. Alleged Research Improprieties and Quality of Care Issues, Department of Veterans Affairs Medical Center Miami, FL, 01-00519-118,...

Issue: Research improprieties. Conclusion: Original consent forms weren't in patients' medical records. Impact: Strengthened research consent policy and improved quality. Complainants alleged that the Chief, Research Section: (i) conducted research on patients without appropriately notifying the health care team of the protocol and did not place informed consents in the medical records; (ii) did not use sound clinical judgment in the treatment of six patients; and (iii) discontinued grand rounds and omitted home care staff from discharge planning rounds. We did not confirm that the chief failed tousle sound clinical judgment in treating the six patients. However, we substantiated that the chief had discontinued rounds and omitted home care employees from discharge planning rounds. We also noted that original consent forms were not always in the patients' medical records. The Director concurred with our recommendations and provided acceptable implementation plans. Alleged Research Improprieties and Quality of Care Issues, Department of Veterans Affairs Medical Center Miami, FL, 01-00519-118,

Veterans Health Administration Quality of Care In response to a Hotline inquiry, an investigation by the VHA Office of the Medical Inspector found that a veteran's treatment for bladder cancer was delayed. Although the veteran was held responsible for this delay because he refused to be treated by residents, the Office of the Medical Inspector reviewers were concerned that the veteran's request resulted in the delay in treatment of a serious condition. This matter was referred to the medical center's ethics committee for consideration. A VHA review at a VAMC substantiated an allegation of employee disrespect to patients. Since this was the second such occurrence by the employee, management proposed termination. Additionally, the VHA review substantiated an allegation of unnecessary pre-operative tests because the tests had previously been completed another VAMC and the diagnostic results could have been obtained from the other facilities. As a result, the clinical affairs associate director will reiterate the policy of accepting diagnostic results fro mother VAMC. A VHA review found excessive waiting times in a Vamp's neurology clinic. In response to the high demand for services, the facility is currently recruiting for a part time neurologist. Neurological services will also be offered at their community based outpatient clinic. Additionally, the primary care staff is being educated on the proper procedure for referrals to specialty clinics. A VHA review found that an outpatient clinic was experiencing staff shortages because of significant physician turnover. The VAMC initially anticipated being able to absorb the workload into the schedules of physicians who remained. However, management has since reassessed this position and increased efforts to recruit additional staff and negotiate contracts with the affiliated university to provide services. A VHA review found there was a 21-minutedelay in transporting a work therapy grounds employee to the VAMC for treatment. The review revealed the employee was suffering from what appeared to be a seizure or a diabetic episode, and the station bus driver who assisted the employee didn't follow established procedures for notifying the facility about the employee's medical emergency. Management has reissued a station memorandum on emergency medical responses on facility grounds to all division managers for review with all employees. A VHA review found a lack of supervision by attending physicians in the intensive care unit. The attending physician involvement was not routinely documented for 30 percent of the unit patients. The chief of staff met with each specialty director to reinforce the requirement that daily involvement in the care of critically ill patients must be documented without exception, and recommended to the clinical executive board that the attending physician must co-sign all unit progress notes.

A VHA review found the issuance of an incorrect medication and poor communications withal patient. The patient was issued an oral rather than a nasal inhaler. Additionally, the pharmacy filled a partial prescription for the veteran, but neglected to run an extra medication label for the balance of his prescription order. The VAMC has taken corrective actions to reduce the chance of future errors. The pharmacy supervisor corrected the error and the veteran was issued the balance of his prescription refill.

A VHA review found a facility failed to inform a veteran that he had not been placed on the liver transplant waiting list due to serious medical complications. Since the medical complications have been resolved, the patient was accepted at VA's national transplant center. A VHA review found there was a delay in the nursing service's response to a call for assistance and that a nurse made inappropriate comments to a patient's son. As a result, the chief nurse met with each individual staff member involved in the incident to review staff coverage, communication, and customer service. Management is conducting additional training for diffusing potentially volatile situations. Management is also developing policies and procedures governing lunch coverage, appropriate lines of communication concerning change in patient's condition, and the correct procedure for summoning help. A VHA review found a patient improperly received a referral to an outside facility for a magnetic resonance imaging after he was found to be too large for the imaging equipment at the facility. The patient should have been admitted to an observation status bed while a neurologic consult was obtained. As a result, a physician advisor has been made available during off tour admissions to assist the medical officer on duty. Management also stated that a patient will be admitted to a ward or kept in the observation unit when emergency social work services can not be provided during off tours. A VHA review found that erroneous entries were made in a veteran's computerized account for medication that he received. A review of the process identified a computer malfunction in VA's computerized patient record system. As a result, the VAMC notified the national online information system and medical staff have been trained toidentify these computer malfunctions as they occur. A VHA review found an outpatient clinic was delinquent in providing a veteran his x-ray results. The x-ray was taken at a community based outpatient clinic and should have been sent to the VAMC for interpretation, however the x-rays were never received. A second set of x-rays was taken, interpreted, and the results were provided to the veteran. As a result, the facility has implemented a weekly accountability process for diagnostic tests completed off station. A VHA review found a veteran's diagnosis and treatment were delayed. The clinicians' failure to perform an examination and follow up on important laboratory test results resulted in a delay in the veteran's diagnosis of colon cancer. As a result, the clinicians involved were counseled on the correct procedures for diagnostic follow up and screening. A VHA review found a VAMC failed to provide food and medication to a patient, failed to provide instructions to the patient for a new prescription, and allowed an unauthorized individual access to a patient's room. As a result, the facility instituted corrective actions to preclude future occurrences and the VA police arrested the unauthorized intruder. A VHA review found that a veteran was admitted to a VAMC center with an obstructed small intestine and was near death from dehydration because medical personnel had removed fluid from his body, but failed to replace a commensurate amount. Management has initiated review mechanisms to identify potentially adverse patient outcomes.

A VHA review found that an employee reported to work under the influence of drugs, failed to report to duty as scheduled, and failed to follow appropriate leave request procedures. The employee was also observed sleeping at the computer and unsuccessfully drawing a blood sample from a patient. As a result, management proposed removing the employee. Time and Attendance A VHA investigation into allegations of time and attendance abuse found that a VAMC anesthesiology department was being mismanaged. This resulted in confusion among employees about staff schedules and responsibilities, low morale, and a pattern of petty jealousies that led to threats of workplace violence. Following the investigation, the physician manager resigned his position and mandatory training was given to all operating room and anesthesiology staff to address time and attendance, ethical conduct, workplace violence, and sexual harassment. A VHA review found time and attendance abuse at a radiology department. The review focused on the employee's time sheets from August2000 to May 2001 and found that an employee frequently came to work late, as much as an hour, but was charged only for a portion of the tardiness or not charged leave at all. The employee received written counseling and will be charged leave for tardiness and absences not reflected on the employee's time sheets. Additionally, management has scheduled the timekeeper and the employee's supervisors for refresher training on the maintenance of time cards and will closely monitor the employee's tardiness. Management will also take action against the employee's supervisors.

Personnel Issues A VHA review at a VAMC substantiated the allegation of prohibited personnel practices. A nurse whose professional license was suspended had been placed on a leave without pay status by the VAMC. This employee continued to accept her VA paychecks for a period of 78 days. Additionally, her nursing supervisor continued to authorize the suspended employee's timecards indirect violation of the acting director's instructions. The VAMC has proposed removal of both employees. A review conducted by a VAMC determined that a nurse manager failed to follow VA, state, and Federal regulations by ordering a subordinate nurse to take annual leave pending renewal of the nurse's nursing license. To correct the situation, the nurse's annual leave used was reinstated and the nurse was granted administrative leave for those days. Additionally, the VAMC instituted a review of this policy to ensure familiarity and strict compliance with applicable regulations.

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This page was last updated on 10/05/2007 01:02 PM

 editor@VA Malpractice.Info

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