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Probe of Retirement Home Finds No Increase in Deaths

By Steve Vogel
Washington Post Staff Writer
Tuesday, February 12, 2008

A Department of Defense inspector general's report does not substantiate allegations made last year of a rising death rate and serious health-care problems at the Armed Forces Retirement Home in Northwest Washington.

The allegations were forwarded in March to the Pentagon by the Government Accountability Office in a letter warning that residents of the retirement home for veterans "may be at risk." The letter cited allegations of a rising number of deaths, rooms spattered with human waste and veterans suffering from bedsores.

The GAO said the allegations were made by medical personnel at the facility, which is home to more than 1,100 military retirees, many of them veterans of World War II, Korea and Vietnam.

But the inspector general's report, completed last month, says investigators "found no evidence that the death rate at the AFRH was increasing." The rate of deaths declined from 9.65 per 1,000 residents in 2004 to 9.22 per 1,000 in 2006, the report says.

Allegations that an unusual number of residents had to be taken to the intensive care unit at Walter Reed Army Medical Center because of poor care were not substantiated. "Those making the allegations were unable to provide specific results of patient case reviews to support the allegation," the report said.

The inspector general confirmed one case in which a patient was found with maggots in a leg wound in 2006. Eight employees were fired because of the incident, which the home acknowledged last year. Overall, the report says, the number of pressure sores at the home "was not significantly different from the national average."

The allegation of unsanitary rooms was related to an outbreak of norovirus in November, but there was not a widespread problem, the report concludes.

"It's really sad that a federal agency like GAO made public really incendiary charges that just weren't true," said Christine Black, a communications consultant for the home.

At the same time, the report calls for improvements, including updating the medical records process, revising the methodology for tracking deaths, setting up an appointment system to cut down on long waits for medical care, cutting a maintenance backlog and improving communication.

The Defense Department "is satisfied with the IG report and considers the allegations as resolved," said Army Lt. Col. Les Melynk, a Pentagon spokesman. But the Defense Department agreed with the recommendations for improvements and does not consider the matter closed.

Investigators interviewed doctors and nurses from Walter Reed and the Veterans Affairs Department, other employees and retirement home residents.

The issue of health care has divided residents of the retirement home, with many saying they receive good treatment and others describing serious problems.

"It's a whitewash, the same thing we've heard for the last 10 years," resident Robert Devaney, who served with the Coast Guard in World War II, said of the IG report.

A group of residents is moving forward with a federal lawsuit alleging that cost-saving measures have hurt medical care. The suit complains particularly of the unavailability of physicians and dentists, neglect of patients and delays in obtaining prescription drugs.

In December, the U.S. Court of Appeals for the District of Columbia, reversing a lower court's ruling that threw out the lawsuit, ordered that the case be heard.

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