WASHINGTON – The Central Alabama Veterans Health Care System pulmonologist who falsified more than 1,200 patient records kept doing it even after he was caught, and even when he was caught again, little was done to discipline him, according to the U.S. Office of Special Counsel.
The independent federal agency, which investigates whistle-blower cases involving government employees, blamed CAVHCS leadership for what it calls “a lack of accountability,” according to special counsel Carolyn Lerner.
Lerner originally disclosed the case of the Montgomery pulmonologist in a letter last month to President Barack Obama. But in testimony she prepared for the House Veterans Affairs Committee this week, she gave additional details about how the doctor was caught and what actions were taken by CAVHCS leaders.
“The time line and specific facts indicate a broader lack of accountability and inappropriate responses by the (VA Medical Center) leadership in Montgomery,” Lerner wrote to Congress.
The pulmonologist’s case also caught the attention of the chairman of the House Veterans Affairs Committee, Rep. Jeff Miller, R-Fla.
“How in the world can this person still be employed at the VA?” Miller asked.
The special counsel has highlighted the case as an example of weak internal oversight of VA doctors and a failure to fully heed the concerns of VA employees who expose wrongdoing. The agency is one of several investigating widespread problems within the VA, including veterans waiting too long to see VA doctors and the VA covering up evidence of the long wait times.
The Montgomery pulmonologist, who has not been named because the case is still under investigation, copied and pasted old patient data collected by other doctors into new records of the same patients. The copied data included the patient’s chief complaint, findings of the physician’s exam, vital signs, diagnoses and plans of care.
A surgeon first reported the wrongdoing involving six patients late in 2012, according to Lerner’s testimony. The surgeon was alerted to it by an anesthesiologist who was doing an evaluation of a patient before surgery.
In response to the complaint, the CAVHCS management monitored the pulmonologist’s work and confirmed the data was being copied and pasted. The pulmonologist was placed on a 90-day “focused professional practice evaluation.”
But during that 90-day review, the pulmonologist continued the copying and pasting. Yet CAVHCS leadership ended the review, citing “satisfactory performance.”
The whistle-blowing surgeon then notified the Office of Special Counsel that the mismanagement was a threat to veterans’ health and safety. The special counsel referred the case to the VA’s Internal Office of Medical Inspector, which confirmed the pulmonologists’ wrongdoing but not the allegations of mismanagement.
The Office of Medical Inspector, however, recommended that CAVHCS review all of the consults performed by the pulmonologist in 2011 and 2012, which is when they discovered it had happened 1,241 times, “far worse than previously believed,” Lerner wrote.
“Despite confirming the widespread abuse, Montgomery (Veterans Affairs Medical Center) leadership did not change its approach with the pulmonologist, who was again placed on (focused professional practice evaluation),” Lerner wrote. “Montgomery (VA) leadership also proposed a reprimand, the lowest level of available discipline.”
Lerner said her office has asked the VA for more information to determine whether the unscrupulous practice endangered patient health.
“Despite the lack of confirmation on this critical issue, Central Alabama VA Director James Talton publicly stated that the pulmonologist is still with the VA because there was no indication that any patient was endangered, adding that the physician’s records are checked periodically to make sure no copying is occurring,” Lerner wrote.
A spokeswoman for CAVHCS did not respond to a request for comment Friday.
In the congressional hearing Tuesday night, a top VA health official declined to discuss the specifics of the Montgomery case, but he said it is common practice to take historical information from prior notes and reuse the information that doesn’t change.
“But we don’t copy and paste material from … old records into new records as evidence of the current encounter with a patient,” said Dr. James Tuchschmidt, acting principal deputy undersecretary for health at the VA. “We would not tolerate that, we would not support that in the organization. That would clearly represent inferior patient care.”
Lerner said she was not aware of any serious disciplinary action taken against the pulmonologist.
“So this fits the pattern that we’re concerned about, where allegations are concerned, no harm is found to patient health and no corrective action is taken against wrongdoers. And that’s really what I think needs to be fixed,” she said.
The special counsel has encouraged the VA to review the patient records and the specific actions taken by Montgomery VA officials in response to the misconduct.
Lerner said her office continues to receive “a significant number” of complaints from whistle-blowers from VA facilities around the country. The agency has more than 60 pending cases involving allegations to patients’ health and safety.
“These problems would not have come to light without the information provided by whistle-blowers,” Lerner wrote. “Identifying problems is the first step toward fixing them.”
Acting VA Secretary Sloan Gibson last week ordered a restructuring of the Office of Medical Inspector and named a new interim director “to create a strong internal audit function which will ensure issues of care quality and patient safety remain at the forefront.”
San Francisco VA psychiatrist receives suspended 5 year revocation of license to practice as a result of inadequate care of veterans at SF VA
On January 5, 2012, the Medical Board of California revoked the license of geriatric psychiatrist Raymond Deicken. However, the Board set aside the revocation, suspending him instead for 60 days. He was additionally placed on probation for five years with terms and conditions. This was the result of a stipulated decision which Deicken entered into with the Board to settle charges against him which included failure to maintain adequate and accurate patient records and numerous counts of dishonesty, gross negligence and incompetence.
The Board’s Accusation details Deicken’s treatment of four patients at the San Francisco Veterans Affairs Medical Center, primarily for pain symptoms. In each case, Deicken privately prescribed to the patients and kept personal records of their treatment. This secret treatment was not made known to any of the patients’ other health care providers…
Colmery-O’Neil VA Medical Center doctor looses her medical license for misleading Kansas Medical Board
The short-staffed Colmery-O’Neil VA Medical Center is down another doctor after a medical board pulled Kelly Humpherys’ license for misleading board members about prior terminations and suspensions that resulted from concerns about her behavioral health.
VA Eastern Kansas Medical system spokesman Jim Gleisberg confirmed via email that Humpherys, who started work March 10, was no longer active at Colmery-O’Neil as of Nov. 8, the day after her license was revoked.
“When you seek to provide high quality, safe patient care you must evaluate the newly hired doctors,” Gleisberg said. “We are doing that.”
When asked if Humpherys was available to comment, Gleisberg said he believed she had left the state.
Colmery-O’Neil has for months been experiencing a physician shortage that has compromised the facility’s ability to provide in-patient care and perform some surgeries and caused administrators to divert patients to other hospitals.
Amid the shortage, a neurologist at the facility was terminated in May after he was convicted of molesting female patients. Further, there is an active investigation into thousands of pills two other..
|Physician Name:||Vincent A Degennaro, MD|
|Year of Birth:||1946|
|Action:||The physician has agreed to never register or reapply for a license to practice medicine in New York State.|
|Misconduct Description:||The physician did not contest the charge of having been disciplined by the Florida State Board of Medicine for failing to practice medicine with that level of care, skill and treatment which is recognized as being acceptable.|
One year before he was appointed senior executive physician for the Miami VA Healthcare System in 2010, Vincent A. DeGennaro surrendered his medical license in New York, stemming from a disciplinary finding in a Florida case of a patient who died under his care at a Fort Lauderdale hospital.
According to the complaint filed with the Florida Board of Medicine, DeGennaro botched a number of his responsibilities while treating a patient for severe abdominal pain at Holy Cross Hospital in January 2003 — including failing to follow up and misinterpreting X-rays of the patient, failing to respond to the patient’s symptoms and complaints, failing to act on the urgent need for surgery and failing to recognize that the patient had a torn large intestine.
DeGennaro, who remains licensed to practice medicine in Florida, could not be reached at his home in Pompano Beach, where a recorded greeting says messages will not be returned. He also could not be reached through the Miami VA’s public affairs office, which issued a statement in response to interview requests.
“The Professional Standards Board (PSB) here at the Miami VA Healthcare System … found that this action had no bearing on his practice at the Miami VAHS,” Shane Suzuki, public affairs officer for the Miami VA, wrote in the statement. “In addition, the PSB also found that no further action was warranted.’’
DeGennaro’s role is to “oversee clinical operations of the Miami VA Healthcare System,’’ Suzuki said, which includes the hospital in Miami and several community clinics in Miami-Dade and Broward counties. He also sees patients and performs surgeries.
Nationally, the Department of Veterans Affairs has been under intense scrutiny for long patient waits for care and falsified records covering up delays that, in some cases, may have resulted in deaths. Miami VA’s public affairs office has not responded to the Herald’s inquiries about whether the healthcare system keeps secret waiting lists for patient appointments.
Florida’s complaint against DeGennaro details the events in 2003 that led to his discipline. The patient, described in the document by the initials R.B., died four days after showing up at Holy Cross complaining of acute abdominal pain and constipation, and reporting a 20-year-history of Crohn’s disease.
According to the complaint, DeGennaro elected to “hydrate the patient for 48 hours prior to scheduled surgery,’’ and later prescribed Demerol, a narcotic pain killer, and Vistaril, a sedative, when the patient reported moderate to severe pain.
DeGennaro interpreted an X-ray of the patient as showing “air in the colon but not dilated,” but the radiologist noted “abnormal distension,” according to the complaint.
Ex-Des Moines doctor cited in West Virginia VA death
Christopher Carson says that if he’d known what Dr. Robert Finley III had been accused of in Des Moines, he never would have let the surgeon touch his father at a veterans hospital in West Virginia.
Asa Carson, 71, died in 2013 of what the family says were painful surgical complications. His son was stunned to later learn that the Department of Veterans Affairs hospital in Huntington, W.Va., had hired a surgeon who was charged with incompetence by Iowa regulators. Finley agreed in 2011 to pay a $5,000 fine to settle allegations that his mistakes caused the deaths of six Iowa patients and injured three others in 2005 and 2006.
“In my mind, there should be more repercussions,” Carson said. “You shouldn’t be able to just pack your bags and move to another state.”
The Carson family is suing the VA in federal court, contending that Finley bungled three abdominal surgeries on Asa Carson and failed to fix a correctable perforated colon.
Finley, 59, who used to practice at Mercy Medical Center in Des Moines, has denied wrongdoing. He continues to work at the VA hospital in Huntington. He did not respond to requests this week for comment.
If current patients checked Finley’s background on the West Virginia medical board’s website, they would find no hint that he’d been in serious trouble in Des Moines. To find that information, they would have to know to look at Iowa records, or they would have to pay $9.95 to look on a national website.
Asa Carson was proud of his Army service and had faith in the VA, his son said. He was in good health until one night in 2011, when he began suffering severe belly pain. An ambulance took Carson to the VA, where Finley reviewed his case, then discharged him after deciding the pain was due to a hernia, the lawsuit says.
Carson remained in severe pain, and he returned to the hospital a few hours later, the lawsuit says. The staff then did scans on him and determined he had a perforated bowel and an internal infection, the lawsuit says. Finley repeatedly operated on him, but the surgeon failed to stop leaks from Carson’s intestines, which led to more severe infection and a massive hernia, the suit says.
Christopher Carson said Finley is a personable doctor who inspires confidence. But after the third major operation in three weeks, a nurse from the intensive-care unit told the family that the surgeries had been flawed, the lawsuit says. “He came to my father’s sister and said he’d never seen anything like this,” Carson said of the nurse.
The family then demanded a different surgeon, and the VA complied, Carson said. But his father never recovered from the damage that had been done, he said.
VA leaders, who declined to comment, are contesting the lawsuit. The legal file includes a letter from the VA last year offering Carson’s family $37,934 to drop the lawsuit. “While there is no way to quantify your father’s pain and suffering and emotional distress, the VA believes the amount listed above is a fair offer to settle this manner,” a VA lawyer wrote.
Christopher Carson said he didn’t respond to that offer. “Thirty-seven thousand dollars for what my dad experienced? That’s almost an insult,” he said. His lawsuit asks for $1.8 million, but he said he just picked a dollar figure because the process requires plaintiffs to include a specific financial demand. His main point in filing the lawsuit is to hold someone accountable, he said.
Documents filed with the lawsuit show VA officials in West Virginia were aware Finley had issues in Iowa. He told the VA that he had been terminated “for reasons of no cause” from Mercy Surgical Affiliates in Des Moines in 2006, and then suspended from Mercy Medical Center. VA officials wrote in 2010 that they’d discussed the issues raised by the Iowa Board of Medicine, “and it was decided the cases had no merit.” The VA officials wrote that Finley had a good record with their hospital.
The Iowa board filed charges of incompetence against Finley in 2010, accusing him of mishandling nine patients, including six who died. He denied wrongdoing, but he agreed in 2011 to pay a $5,000 fine to settle the Iowa licensing board’s allegations. The board said at the time that Finley had spent a year having his work overseen by another surgeon in West Virginia, and that he had passed a recertification exam.
Mark Bowden, the Iowa board’s executive director, said the settlement was determined to be sufficient. Iowa officials did not put restrictions on Finley’s license, “because the alleged malpractice was five years earlier and he addressed the competency issue through remediation,” Bowden wrote in an email to the Register this week.
Finley began working at the West Virginia VA under his Iowa and Ohio medical licenses, records show. He obtained a West Virginia medical license in 2012.
Any West Virginia consumers who check their state’s website to research the surgeon’s history would see a notation that says “no discipline cases on record.” Robert Knittle, the West Virginia board’s executive director, said his board could have put public restrictions on Finley’s license based on the Iowa allegations, but decided not to.
Bowden, the Iowa regulator, noted that consumers may check a national database to see if a doctor has been sanctioned in any state.
Christopher Carson said he wishes the Iowa board had moved more swiftly and firmly against Finley. It should not have taken four years to investigate the problems, and the $5,000 fine was “essentially a traffic ticket,” he said.
Carson said that in order to file a malpractice lawsuit, he needed to find an outside expert who would agree that the death was caused by malpractice. An Ohio colorectal surgeon who reviewed the case concluded that Finley’s mistakes caused Asa Carson to suffer and die.
Carson views his father’s mistreatment as part of a pattern of troubles at VA hospitals nationwide. “They keep making this argument that they need more doctors. But they shouldn’t pick just anybody,” he said.
Carson said he didn’t find out about Finley’s Iowa troubles until he consulted a lawyer, who researched the surgeon’s history. He said he’s asked his wife to make similar inquiries if he ever needs emergency treatment.
“I want her to do due diligence to make sure I don’t end up with a Dr. Finley,” he said.
The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.
In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.