Travis Andersen can be reached at email@example.com.
The Veterans Affairs Department wasted more than $3 billion over 10 years on medical implant purchases — and is now losing track of those implants once they’ve been put into patients, potentially putting veterans’ health at risk, according to a new watchdog report that’s drawing attention from members of Congress.
“Spending taxpayer dollars wisely is essential, but providing the health care that veterans have earned and deserve is critical,” said Rep. Ann Kirkpatrick, the ranking Democrat on the House Veterans’ Affairs oversight subcommittee.
Investigators found the department’s Veterans Health Administration was often buying the implants on the open market, instead of using pre-existing federal contracts where lower prices had already been negotiated. Investigators said one official at a government hospital agreed to pay $6,000 for a device with no further review because similar items usually sold for “between $3,000 and $20,000.”
In May 2012, the Government Accountability Office, the nonpartisan investigative arm of Congress, calculated the VA had overpaid by $3 billion over the previous decade to purchase the implants. The watchdog agency told The Washington Times it hasn’t yet analyzed the amount of waste in 2013, but with an estimated $563 million going to the purchases in 2012 — 28 percent more than the last four years — there’s a lot of potential for abuse.
For wasting billions of dollars and potentially putting veterans’ health at risk, the Veterans Affairs Department wins this week’s Golden Hammer, a distinction from The Washington Times given out to mark examples of fiscal waste, fraud and abuse.
VA officials insist that fixes to the problems are underway.
“The Veterans Health Administration has made significant changes in the last three years to the way we procure surgical implants and prosthetic appliances for veterans,” said Philip Matkovsky, the VA’s assistant deputy undersecretary for health. “These changes are intended to improve procurement performance and accountability while ensuring effective health care delivery for our veterans.”
“It is troubling to consider that for these specialties, VHA was unable to verify that the items purchased were actually implanted in the patients for which they were intended,” said Rep. Mike Coffman, the Colorado Republican who chairs the oversight subcommittee, which held a hearing Wednesday to investigate the problems. “Proper tracking of surgical implants is a problem that has been unresolved for far too long and it must be remedied posthaste.”
Without information to find patients who have certain implants, the VA can do little in the event of a product recall or safety announcement, the GAO said, meaning some veterans could potentially be walking around with degrading or harmful medical devices inside their bodies.
Randall Williamson, the GAO’s director of health care, said the VA started a system in 2008 to track all the implants, but efforts to implement it are currently stalled because of technical challenges and a lack of funding.
The GAO investigators also said that VA officials have been too reliant on waivers that allow them to pursue purchases on the open market and ignore lower-priced avenues available from the government. The waivers are supposed to allow doctors to purchase specific items that aren’t available from government suppliers if it would be a better fit and greater help for a veteran.
But investigators said VA medical officials largely seemed to be ignoring long-established ways to buy items and instead routinely relied on the waivers. One hospital used waivers for 90 percent of the purchases investigators reviewed.
Earlier this month, I returned to Augusta to participate in an oversight visit with U.S. Rep. Jeff Miller of Florida, chairman of the House Committee on Veterans’ Affairs to get to the bottom of the problems plaguing the Charlie Norwood VA Medical Center. Along with my colleagues – U.S. Reps. Phil Gingrey and John Barrow of Georgia, and U.S. Rep. Joe Wilson of South Carolina – I questioned the VA hospital staff on how, when and why the lapses in patient care resulting in the deaths of Georgia veterans occurred, and who was ultimately responsible.
Morris still employed by the VAAide charged with criminal deviate conduct
Posted: Thursday, January 23, 2014 4:00 am
A nursing aide charged with performing oral sex on a patient is still employed at the VA Hospital, officials say.
According to emailed information from Mike Brady, public information officer for the VA Northern Indiana Health Care System, Scott Morris was hired at the VA Hospital in January 2002.
A traveling medical technician who infected dozens of patients in multiple states with hepatitis C through tainted syringes has been sentenced to 39 years in a New Hampshire prison.
David Kwiatkowski, 34, worked as a cardiac technologist in 18 hospitals in seven states, including Maryland before being hired at New Hampshire’s Exeter Hospital in 2011, moving from job to job despite being fired at least four times over allegations of drug use and theft. Since his arrest last year, 46 people in four states have been diagnosed with the same strain of hepatitis C he carries.
Kwiatkowski worked at four hospitals in Maryland, including the VA Hospital in Baltimore, Johns Hopkins, and Maryland General.
“I don’t blame the families for hating me,” David Kwiatkowski said after hearing about 20 statements from people he infected and their relatives. “I hate myself.”
Kwiatkowski, who has admitted stealing painkillers and replacing them with saline-filled syringes tainted with his blood, pleaded guilty in August to 16 federal drug charges. He was to be sentenced Monday.
“There’s no excuse for what I’ve done,” he said. “I know the pain and suffering I have caused.”
Prosecutors asked for a 40-year sentence. Judge Joseph LaPlante said he cut the last year as a reminder that some people have the capacity for mercy and compassion.
“It’s important for you to recognize and remember as you spend the next 39 years in prison to focus on the one year you didn’t get and try to develop that capacity in yourself,” LaPlante said.
The victims spoke angrily and tearfully of the pain that Kwiatkowski had inflicted by giving them hepatitis C, a blood-borne virus that can cause liver disease and chronic health problems.
Linda Ficken, 71, was one of two Kansas victims to attend the sentencing hearing. She underwent a cardiac catheterization at Hays Medical Center in 2010, and said she is haunted by the memory of Kwiatkowski standing at her bedside for more than an hour, applying pressure to the catheter’s entry site in her leg to control bleeding.
“On one hand, you were saving my life, and on the other hand, your acts are a death sentence for me,” Ficken, of Andover, Kan., told him Monday. “Do I thank you for what you did to help me? Do I despise you for what your actions did and will continue to do for the rest of my life? Or do I simply just feel sorry for you being the pathetic individual you are?”
Linwood Nelson, who was infected when he went in for a procedure at the Baltimore VA Medical Center in 2012, said Kwiatkowski “should receive the same punishment he gave us: the death penalty.”
In pushing for a 40-year prison sentence, prosecutors said Kwiatkowski created a “national public health crisis,” put a significant number of people at risk and caused substantial physical and emotional harm to a large number of victims.
Defense lawyers argued that a 30-year sentence would better balance the seriousness of the crimes against Kwiatkowski’s mental and emotional problems and his addiction to drugs and alcohol, which they said clouded his judgment.
In all, 32 patients were infected in New Hampshire, seven in Maryland, six in Kansas and one in Pennsylvania. Kwiatkowski also worked in Michigan, New York, Arizona and Georgia.
Two of the 16 charges stem from the case of a Kansas patient who has since died. Authorities say hepatitis C played a contributing role.
Ficken told The Associated Press last week that while she has struggled with fatigue since her diagnosis, a bigger blow came last month when her brother was diagnosed with leukemia and was told he needs a stem cell transplant. While siblings often are the closest match, she can’t donate because of her hepatitis C status.
She made a tearful promise to Kwiatkowski if her brother dies because she can’t be a donor.
“Rest assured, I will haunt you until the day I die,” she said.
ALBUQUERQUE, New Mexico — A lawsuit filed by a chaplain at the Veterans Affairs medical center in Albuquerque contends that a supervisor harassed and tormented her after improperly accessing her VA medical records that included a psychological profile.
The Albuquerque Journal (http://bit.ly/18TTT66 ) reports that the U.S. Attorney’s Office denies the allegations in the suit filed by Kathleen Waltz against the federal government.
According to the lawsuit, the supervisor’s alleged actions violated Waltz’s privacy rights and she has suffered severe emotional distress as a result.
The lawsuit also alleges that the supervisor began a campaign of harassment and mistreatment of her against she complained about mistreatment of another employee
December 2, 2013 (WLS) — A Chicago-area Vietnam veteran will get a $12 million medical malpractice settlement from the federal government.
John Johnson suffered severe brain damage during surgery at the Hines VA Hospital five years ago.
His lawyers say doctors did not adequately prepare for and monitor his heart condition when he was put under anesthesia.
His lawyers say the money will be used to help cover his medical and day-to-day living expenses.
Board revokes doctor’s license at Topeka VA hospital
- Published Sunday, Nov. 24, 2013, at 2:58 p.m.
- Updated Monday, Nov. 25, 2013, at 6:18 a.m.
TOPEKA, Kan. — A medical board has revoked the license of a doctor at an already short-staffed Topeka veteran’s hospital.
The Oklahoma Board of Medical Licensure and Supervision cited incompetence in pulling the plug on Kelly Humpherys license on Nov. 7. Humpherys had been licensed and practiced medicine in Oklahoma before starting work in March at the Colmery-O’Neil VA Medical Center, The Topeka Capital-Journal (http://bit.ly/17IHJfg) reports.
VA Eastern Kansas Medical system spokesman Jim Gleisberg said in an email that Humpherys was no longer working at the Topeka facility. Humpherys doesn’t have a listed number in Topeka, and Gleisberg said he thought she had left Kansas.
The Oklahoma licensing board found she had problems in her Oklahoma job and hadn’t been forthcoming about problems in her previous stops.
Humpherys graduated from the University of Kansas School of Medicine in 2000, but was placed on probation for “poor medical judgment” during her OB-GYN residency and ultimately terminated when she failed to complete the terms of her probation.
In her licensing application, Humpherys told the Oklahoma board she “took a leave of absence to care for her ailing mother” and, during that leave, decided OB-GYN wasn’t the right specialty for her.
She switched to family medicine and practiced in Arkansas within the St. John’s Health System. According to the board’s investigation, her privileges were suspended there in April 2008. David Barbe, a doctor with St. John’s, referred Humpherys to the Professional Renewal Center in Lawrence “as a result of concerns regarding disruptive behavior in the workplace.”
The staff at the Lawrence center recommended six to eight months of intense treatment for Humpherys. She resigned from St. John’s instead and didn’t disclose the suspension of privileges to the Oklahoma board when she obtained her license there four months later. Instead, Humpherys explained her four-day evaluation stint at the Professional Renewal Center by telling the board that St. John’s had sent her there to “conduct an assessment of the facility.”
At Jane Phillips Medical Center in Bartlesville, Okla., her obstetrics privileges were suspended after administrators deemed her “an immediate threat to health and safety.” She appealed that decision, but an appeals committee upheld it on June 6, 2012.
Finally, on Feb. 29, the downtown branch of the Augusta hospital performed an endoscopy and diagnosed the disabled veteran with pancreatic cancer.
Six days later, the 83-year-old Army paratrooper – who received an honorable discharge in 1962 for his service in World War II, Korea and Vietnam – died from complications related to his disease.
“I knew my father was dying just by looking at him,” said Dana Hartmann, of Martinez. “Not one X-ray was done, or one MRI taken. The VA just let him go.”
Wilson’s family links his death to the center’s embattled gastrointestinal program.
Hospital administrators admitted this week that it botched the clinic so badly that consultations were delayed unnecessarily for 5,100 veterans between 2011 and November 2012.
The medical center’s executive office has put the death toll at three cancer patients, but Wilson’s family and one former employee said the issue dates back eight years and might include more deaths, possibly connected to the administration of former Director Rebecca Wiley.
According to a 2012 report from the VA Inspector General’s Office, Wiley, whose tenure in Augusta lasted from 2007 to 2010, is responsible for nearly 90 percent of the medical center’s unresolved consults, along with the hospital’s loss of full accreditation three years ago.
The ongoing investigation found that mismanagement during some of Wiley’s time in Columbia, which began in November 2011, contributed to a backlog of nearly 4,000 gastrointestinal appointment delays, which in turn led to 19 instances of serious injury and six patient deaths.
Hospital spokesman Pete Scovill said Friday that Norwood officials have provided information on how to file a lawsuit to seven families in an effort to take responsibility for four serious injuries and three deaths.
Citing patient confidentiality, Scovill would not say whether Wilson’s death is one of the three, but he said the hospital has reached out to the family and is working with them the best it can, possibly to help it collect damages.
Hartmann said she has kept all her father’s medical records and her family is speaking with an attorney.
They said they’ve been told they have a strong case.
“I want them to pay or at least personally apologize for the pain they caused my families and others,” said Kelly Alsuhaim, Wilson’s granddaughter.
Hartmann believes her father could have been saved – or at least been in a lot less pain before his death – had the VA listened.
Starting in 2010, her father, a non-diabetic, reported elevated liver enzymes and glucose levels that were not high enough for his pancreas to make insulin. Hartmann said her father’s doctor scheduled many appointments at Charlie Norwood for exploratory testing, such as an endoscopy.
Each time the sessions were pushed back and Wilson was sent home, his pain written off as a product of old age, ulcers, minor gastric problems, lung infection. At one point, the hospital told him it was “all in his head,” a byproduct of depression after the death of his wife.
“They told him to modify his diet, but what really was happening is his bile ducts were being blocked and his pancreas was shutting down,” Hartmann said.
Catherine McAdams, a 28-year operating room nurse at Charlie Norwood who left the hospital’s infection control unit in October 2008, said that under Wiley, it was not uncommon for administrators to turn a blind eye to gastrointestinal patients.
She believes there might be more deaths related to colonoscopies and incompetent care.
In June 2005, McAdams went full time as a staff nurse at the medical center’s spinal cord injury unit. During her first week, while shadowing a wound care specialist, she tended to a veteran who had a procedureto reroute his bowels for better bladder control. McAdams and the specialist discovered that two-thirds of the patient’s colon had died, and his vital signs were fading.
“They didn’t do anything,” McAdams said. The veteran spent three weeks in intensive care and eventually died. “They let him sit for seven days on the spinal cord injury unit, writhing in pain.”
She said she knows of at least four deaths linked to surgeons using leaky feeding tubes or improperly sterilized endoscopes to operate on Army veterans from the Korean and Vietnam wars, some of whom ranked as high as captain.
McAdams said she reported the incidents in 2008 to the VA. She said she wished she had done so sooner.
“You don’t understand the culture of the VA under Wiley,” she said. “It was intimidating and retaliatory.”
McAdams said she plans to contact the House Committee on Veterans Affairs to help with Congress’ investigation into gastrointestinal mismanagement in Augusta and Columbia.
In September, the committee requested copies of all current accounts of appointment backlogs and patient injuries. It also asked for any records reflecting performance reviews, pay bonuses and disciplinary actions issued since 2002 to those who oversee patient safety in Augusta.
Charlie Norwood officials said they have complied with the request and have added resources and made personnel changes to the hospital’s gastrointestinal program to reduce the backlog to 540 unresolved screenings.
Scovill said the hospital takes all complaints seriously and invites all veterans to call its patient advocate director, Donna Ingram, at (706) 733-0188 if they feel they are owed compensation or in need of further assistance.
“They’re better off working within our system and giving us a second try to make it right,” Scovill said. “After that, they can file an appeal and take it to court.”
Hartmann said the VA is out of chances, as far as she is concerned.
“I have been trying to get somebody to listen to me for three years,” she said. “But nobody would.”
COLUMBIA, South Carolina — Officials say the operating rooms at the Department of Veterans Affairs hospital in Columbia should reopen next week, nearly two months after dust particles were found on supplies.
Authorities said a disintegrating filter caused the dust. The operating rooms at the Dorn VA Center were shut down on Oct. 18 and surgeries were moved to other offices outside the hospital.
Officials say the dust was part of a special filter that disintegrated. The maker of the filter told the VA it has never seen anything like that happen.
Workers thoroughly cleaned the operating rooms, while doctors reviewed more than 1,000 operations going back to the summer. They found six infections, but determined none of them were caused by the dust.