The Department of Veterans Affairs’ top health official on Monday told a House committee hearing into “preventable deaths” at VA medical facilities that the incidents do not represent systemic problems for the department.
The hearing, held in Pittsburgh at the Allegheny County Courthouse, featured tearful testimony from veterans’ families who had troubling and, in some cases, tragic interactions with VA medical facilities in Pittsburgh, Atlanta, Buffalo, Dallas and Jackson, Miss.
“The patient care issues the committee has raised are serious, but not systemic,” Robert A. Petzel, VA’s undersecretary for health, told the House Committee on Veterans’ Affairs, which held the hearing. The hearing was titled, “A Matter of Life and Death: Examining Preventable Deaths, Patient Safety Issues and Bonuses for VA Execs Who Oversaw Them.”
The VA “has consistently given executives who presided over these events glowing performance reviews and cash bonuses,” complained Rep. Jeff Miller (R-Fla.), chairman of the committee.
“The systems have failed, and those who run the systems have not been held accountable,” Miller said.
In Pittsburgh, where five veterans’ deaths have been attributed to Legionnaires’ disease, VA officials knew they had an “outbreak on their hands, but they kept it secret for more than a year,” Miller said.
The family of Robert E. Nicklas, an 87-year-old veteran who died from the disease in November, testified that they were not told of an ongoing investigation into the outbreak while he was a patient.
Miller noted that Michael
Moreland, who oversees a VA medical region that includes the Pittsburgh office, got a $63,000 bonus three days after the VA inspector general reported that Pittsburgh’s response to a deadly outbreak of Legionnaires’ disease was plagued by mismanagement.
“It is absolutely unconscionable that we would provide bonuses to anyone responsible for preventable deaths,” Miller added.
Moreland received a Presidential Distinguished Rank Award in April, the same month the IG report was issued.
“The timing of that was very bad,” Moreland acknowledged during questioning.
Petzel said the VA has held off on taking administrative action in Pittsburgh until the department’s inspector general completes an investigation to decide whether to recommend criminal charges.
In Atlanta, IG reports faulted mismanagement for the overdose of one patient and the suicides of two others. In Buffalo, at least 18 veterans tested positive for hepatitis after it was discovered that the medical center had been reusing disposable insulin pens.
The medical centers in Jackson and Dallas are the subject of numerous allegations of poor patient care, Miller said.
Petzel provided the committee with details on disciplinary actions taken in connection with the events, but did not discuss them publicly.
In Atlanta, Petzel added, “the people responsible have been held accountable.”
Miller, who received the VA’s report on Sunday, retorted, “There may have been action taken, but I don’t know that they were held accountable.”
Petzel said the VA has taken steps to avoid a repetition of the problems that have surfaced in connection with the incidents, including the spread of Legionnaires’ disease in Pittsburgh.
“Lessons learned from Pittsburgh, and they are extensive, are now being used to ensure water safety at all VA medical centers throughout the nation,” Petzel said. The Buffalo incident has “triggered a national change in how our system manages the use of insulin pens,” he added.
Addressing families present at the hearing, Petzel added, “I am saddened by the stories of loss that I have heard from the families, and I offer my sincerest condolences to the families here today.”