New Mexico VA Hires Surgeon Who Has Been Disciplined in 2 Other States For Operating on the Wrong Part of the Patient’s Spine!
Dr. Frank Allen Zimba has been practicing medicine for 31 years, is board certified in neurological surgery – and has a disciplinary history in two other states of operating on the wrong part of his patients’ spines.
The 57-year-old Texas native was hired at the Veterans Affairs hospital in Albuquerque last August, even though disciplinary proceedings that resulted in a suspension of his Oklahoma medical license were pending.
The VA in Albuquerque isn’t saying whether Zimba has had any problems on the job so far – claiming it would be a personnel matter. But even if there have been, the state Medical Board has no jurisdiction to investigate.
That’s because under federal law Zimba is not required to be licensed in New Mexico, unlike most other physicians who work here. He only needs to be licensed in one state in the country, and he has licenses in Oklahoma, New York, Michigan and Pennsylvania.
That left Zimba – who, through a VA spokeswoman, declined to be interviewed for this story – able to work at the Albuquerque VA Hospital during the six months his Oklahoma license was suspended.
Disciplinary records show Zimba was suspended for allegedly operating on the wrong part of a patient’s spine in February 2010. The suspension ended in March of this year.
Several years earlier, he was alleged to have performed surgery on the wrong side of two patients’ spines at a hospital in Jamestown, N.Y.
“They call it a never event,” said Oklahoma assistant attorney general Libby Scott, because it should never happen if hospitals follow procedures and properly mark the sites for surgery.
“But it could happen to good surgeons,” she added. Still, Scott said, three mistakes in a four-year period is troubling.
“Either this is the most unlucky guy in the world or there’s something wrong here,” Scott told the Journal last week.
In two of the three surgeries, Zimba also failed to tell the patients or their families afterward that he had made the errors, according to Zimba’s disciplinary records.
Zimba attributed the mistakes in New York to problems with the markings of the surgical sites. Either the markings weren’t there, or were incorrectly placed, he told the Oklahoma Board of Medical Licensure & Supervision in a 2009 statement.
“No medical harm befell either patient,” he added.
Scott, who advises the board, recalled that after the more recent error in Oklahoma, Zimba blamed a blue dye that was used to mark the spot for surgery.
“Either the dye moved or didn’t go in right, so he was on the wrong side … and no one really stopped him,” she added.
The patient, who was in the U.S. military, is suing Zimba and Southwestern Medical Center in Lawton, Okla., where Zimba was employed. The patient is alleging that he suffered injury as the result of negligence during the surgery.
Scott said hospitals have instituted “time outs” before a surgery, so that “before you cut, the whole operating room stops, they have a checklist to go over … to make sure everyone is on the same page and doing the correct thing.”
“Most people, when a bad thing happens it makes them so paranoid that they double check and triple check.”
Zimba went to work for the VA hospital in Albuquerque after his disciplinary process began but before any penalty was imposed by the state of Oklahoma.
The Oklahoma medical board filed a complaint last June accusing Zimba of unprofessional conduct and asked him to respond at a July hearing.
The hearing was postponed, and in late August 2011 Zimba started work as a staff physician in surgery service at the VA hospital in Albuquerque.
This January, he entered into a settlement agreement with the Oklahoma board, which suspended his medical license retroactively from September 2011 to March of this year.
“He told us he had this job in New Mexico, and we told him we wouldn’t settle on anything less than a six-months suspension,” Scott said.
Sonja Brown, a VA hospital spokeswoman in Albuquerque, said she wasn’t able to disclose why Zimba was hired despite his disciplinary history.
She also declined to say whether he had performed within the standard of care since his hiring or whether he had been disciplined or otherwise suspended for any length of time.
Those issues “are confidential personnel matters that I am not able to disclose,” she told the Journal in an email.
Matters of jurisdiction
The New Mexico Medical Board oversees the licensing for more than 7,500 physicians. But it doesn’t investigate complaints about physicians who aren’t licensed here.
“The patient would have to file a complaint with the state licensing board with whom he/she is licensed,” said spokeswoman J.J. Walker in an email.
Zimba’s medical license is still active in Oklahoma, but Scott said her board probably wouldn’t investigate a complaint made by a New Mexico patient.
“Because our duty is to protect the public and citizens of Oklahoma, so … if it’s not an Oklahoma patient, it’s really not in our jurisdiction.”
As to the lack of oversight by a state licensing board, “That’s a problem obviously,” Scott said. “We have a lot of Indian facilities in Oklahoma, and most of them nowadays are requiring an Oklahoma (medical) license for that very reason.”
Brown, the VA spokeswoman, said VA policies and federal regulations are designed to “protect BOTH the patient and the practitioner.”
Under the in-house system, the VA physician’s supervisor investigates patient complaints and reports the findings to the facility leadership if a complaint is substantiated.
Brown cited a federal regulation that requires the VA to report to state medical boards any physician whose clinical practice “so significantly failed to meet generally accepted standards of clinical practice … as to raise reasonable concern for the safety of patients.”
Some examples: errors in medication, substance abuse, patient neglect, and unethical behavior or abuse of a patient.
New Mexico medical board spokeswoman Walker said Friday that no one in her agency could recall ever receiving such a report from the VA.
The New Mexico board maintains a public website that lists basic information about its licensed physicians, including disciplinary actions taken.
Back to Oklahoma?
Zimba told the Oklahoma Medical board on his 2009 license application that he served in the U.S. Army from 1976 to 1994 and graduated from the University of Texas Medical School in Houston.
He also disclosed that he was sued for malpractice in 1997, a case that settled for $400,000.
Zimba’s disciplinary records also revealed that he had received a reprimand, probation, fines and one year of monitoring in 2008 related to the New York surgical errors.
His license in Oklahoma is up for renewal in September.
But if Zimba ever wants to return to work there, he must first appear before that state’s medical board, Scott said.
“We obviously were concerned … without some kind of re-education, would you want someone coming back like that? The board would have to decide … if they think he is competent or not.”
VA Nurses Scrutinized After Patient Deaths in Two States
by Tracy Weber and Charles Ornstein ProPublica, April 30, 2012, 12:19 p.m.
After a patient died last year at a Veterans Affairs hospital in Manhattan, federal inspectors discovered nurses in his unit had a startling gap in their skills: They didn’t understand how the monitors tracking vital signs worked.
None of the nurses interviewed could accurately explain what would happen if a patient became disconnected from a cardiac monitor 2014 which allegedly occurred to the patient who died, <a href=”http://www.va.gov/oig/pubs/VAOIG-11-02545-15.pdf“>according to an October 2011 report</a> from the U.S. Department of Veterans Affairs’ inspector general.
The incident followed two deaths in the <a href=”http://www.va.gov/oig/54/reports/VAOIG-09-01047-69.pdf”>cardiac monitoring unit at a VA hospital in Denver that raised similar questions about nurse competency. Earlier this month, www.va.gov/oig/pubs/VAOIG-12-00956-159.pdf a broader review by the VA inspector general</a> of 29 VA facilities found only half had adequately documented that their nurses had the needed skills. Some nurses “did not demonstrate competency in one or more required skills,” but there was no evidence of retraining, the report said.
An outside nursing expert who reviewed the reports at ProPublica’s request called them “troubling” and said the fact that the lapses weren’t caught and corrected “signified much broader problems.” The inspector general’s findings reveal “a lack of oversight and adherence to accepted clinical and regulatory standards,” said Jane Hirsch, a clinical professor emeritus at the University of California, San Francisco School of Nursing, who previously oversaw nursing at U.C. San Francisco Medical Center.
The April 20 IG report also noted that previous inspections had found nurse competency issues in “dialysis, mental health, long-term care, spinal cord injury, endoscopy procedure areas, the operating room and the cardiac catheterization laboratory and with reusable medical equipment.” In a response to the inspector general, the VA pledged to create uniform competency standards for its 152 hospitals and to ensure that evaluations of every nurse’s skills are up-to-date. Nurses will not be able to work in areas in which they have not demonstrated competency. </p><p> A VA spokeswoman declined further comment. </p><p> Nurse competency has increasingly become an issue in medicine. Hospitals and clinics create their own procedures and tests for assessing the skills of nurses, but their <a href=”http://www.propublica.org/series/nurses”>adherence to these policies is spotty<
Outside regulators don’t test individual nurses, but simply check if a sampling of the nurses’ files have the appropriate paperwork certifying competency. </p><p> That’s what VA’s inspector general did for the April review. As such, officials acknowledged that they could not verify whether nurses at those hospitals, or others, are providing competent care. </p><p> “We did not look at actual care or actual competence,” Julie Watrous, director of the inspector general’s combined assessment program, which inspects each VA hospital every three years, told ProPublica.
Only half the 29 facilities included in the new report had complete nurse skill assessment records that met the hospitals’ standards, inspectors found. Of the 349 nurses whose files were examined, paperwork showed that 58 lacked skills in at least one area. And for 24 in that group, there was no evidence that anything was done in response. </p><p> In an interview, however, the IG official who coordinated the report said she was generally pleased with the findings. Although both the VA and its hospitals had room to improve, she said, all of the hospitals had policies in place and at least some proof of skills in each nurse’s file. </p><p> “We never found one single site or even person that didn’t have at least components of competency assessment and validation,” said Carol Torczon, associate director of the St. Petersburg, Fla., office of the inspector general. “Where we found the holes was in the paper process.”
Torczon said she believed that the problems identified in Denver and New York were not reflective on the care generally provided by VA nurses in cardiac monitoring units. Inspectors in the New York and Colorado cases said they could not definitely tie the deaths of the patients to their nurses’ care. But they noted that their lack of training put patients at risk.
Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes. </p><p> After the patient in New York died, inspectors quizzed nurses and a biomedical engineer about what would happen if a patient got disconnected. “According to some staff, a ‘red alarm’ would be triggered since a disconnected lead was considered critical,” the report said, “whereas other staff told us that a disconnected lead would trigger a yellow alarm or that it would not trigger any alarm at all.”
Inspectors also found no evidence that the nurses’ competence had been checked. Records showed that one of the patient’s nurses had last received training on the monitors 13 years earlier. Two years earlier at a VA hospital in Denver, inspectors looked into the deaths of two patients on cardiac monitors. After the first death, the hospital gave nurses a basic test of their ability to interpret monitor readings: only one of 28 passed, www.va.gov/oig/54/reports/VAOIG-09-01047-69.pdf according to a January 2010 report. The nurse in charge when both patients died had never received specialized training in cardiac monitors. Even after the second patient died in 2009, inspectors found “it was unclear who was responsible for telemetry training, and staff were not aware that policies had been updated.”
Both facilities vowed extensive reforms in responses that were included in the IG reports.
Experts say up-to-date competency evaluations are important because they ensure that nurses, who provide the bulk of the frontline care in hospitals, have the skills for their position.
“It would appear that the old adage ‘inspect what you expect’ has most certainly not been taken very seriously in these environments,” said Hirsch, who was chief nursing officer at UCSF Medical Center for nine years.
Is it really a surprise the way that the Pittsburgh VA leadership has handled the Legionnaires outbreak?
In 2009 the Pittsburgh VA closed a swimming pool that veterans used for aqua therapy due to financial considerations; however, in 2010 VAI remember when I was commissioned being told that a government traveler is a frugal traveler, and that per diem was based on the amount that a frugal person needed. When I was young you could always identify a government building because it was a plain, sturdy, functional building. There almost no need to put a sign on Post Offices, when I was a kid, because they all looked the same. This article makes it clear that the VA’s mindset has changed, and that a VA traveler does not to be a frugal traveler.
Veterans Angered By VA Executives’ Office Space
I thought that this article showed an unusual insight into why the VA seems to never manage to clean up the quality of medical care that it provides to veterans,
…the social elite of the armed forces are not admitted, either. President Eisenhower was unquestionably a veteran, but he had his famous hospitalizations at Walter Reed Hospital. There’s an income limit for VA admission, which automatically cuts off 20-year veterans above a certain rank, possibly major. And there are overlapping disability classifications for military hospitals and veterans facilities, with considerable latitude available to uniformed boards of three serving officers, only one of whom is a physician. The result is a general perception that if you have any influence at all, you can generally avoid the VA and be treated in a military hospital, probably in a VIP unit. Good for them; I’d take advantage of it if I had a chance, too. But by siphoning off the top brass, a lot of pressure to improve quality is removed as well. If a VA hospital had eight or ten Admirals and Generals as patients, with academy classmates coming to visit, it’s safe to assume that courtesy, orderliness and cleanliness would instantly improve. And take it from me, the quality of care would improve, as well.
By Elise Cooper
Many veterans feel disconnected with the VA. They regard it as a huge bureaucracy that is very impersonal and unhelpful. The vets get frustrated because they do not know where to turn for help. American Thinker interviewed veterans and others involved with the VA to reveal some personal examples and to see if the complaints are justified.
Perception is reality, and no matter how the VA administrators try to sugarcoat the problems, they still exist. Retired Army Colonel David Sutherland sees the problem as originating from the time the soldier makes the transition from military to civilian life. He explained that the troops deploy as units, not as individuals; yet, as they arrive home “the bonds formed on the battlefield are ripped apart which creates this disconnect. There must be a recognition that each vet is a unique individual.”
Retired Army Major Ben Richards agrees, and cites his personal experience, having received a traumatic brain injury while fighting in Iraq. “I have such low regard for the VA. I have never been treated in my life as poorly as I had with the VA. I get more stress when I think about going there. My experience is that people blame others or pass the buck to someone else.” He told his story of how a VA doctor reviewing his condition had not even read his records, and showed no personal regard for him. He considers himself one of the lucky ones since he was able to seek outside help from a doctor who is providing pro bono services.
A former Marine, Mike Liguori, who has written the book, The Sandbox, was diagnosed with PTSD. He also did not find the VA helpful because their prescribed treatment was to take medication. “My attitude was I don’t want to take pills just because you tell me I will feel better. The person I dealt with was cold-hearted. They made me feel like they had no time for me. All they did was to take notes, never engaging with me, and after ten minutes decided to write me a pill prescription. I was never told about alternate forms of therapy. What finally helped me was working with someone on the outside who taught me meditation.”
A former Army Sergeant is also very unhappy with the VA. She told American Thinker how a friend had PTSD and went to the VA for help, but was told he had to wait a few months to get an appointment. “What he ended up doing was smoking himself.” A Veterans’ Committee source told American Thinker that the average wait is 50 days for an initial consultation.
Everyone also has a complaint about the amount of paper work that must be filled out to get an appointment. Debbie Lee, whose organization America’s Mighty Warriors, concurs, and describes all the documentation that must be filled out as a mountain of paperwork six feet tall.
Lee agrees with all the complaints regarding the VA. “In helping vets get issues resolved I have not heard very good things either. Many have to wait months to get an appointment, when they finally have that appointment they have to wait a huge amount of hours, and if they miss an appointment for some reason they must start the process over. There is also the problem of having to travel hours and having to take off a full day just to have an appointment. For example, a vet here in Arizona that I was helping had to travel forty-five minutes to get to the VA and after arriving was told the appointment was cancelled. It is despicable the way they are treated. The VA does not want to admit they are failing.”
Pete Hegseth, a former Iraq and Afghanistan veteran who is now CEO for Concerned Veterans For America told American Thinker that there is also a problem with the backlog, that pending claims have risen from 300,000 when Obama became President to 900,000, causing an average wait time of approximately 273 days. According to Hegseth, part of the problem is that “the VA needs to join the 21st Century. Over 90% of the claims are still done on paper instead of digitally. Processing times suffer because of the delay created by the paperwork. The VA must adapt to a model that provides claim resolutions when and how veterans want, rather than when and how the department wants.”
Part of the problem pointed out in the video Veteran Nation by James Carafano is that during and after each war there is a uniqueness to how the veterans are treated as well as the specific type of injuries. The Iraq and Afghanistan Wars have one out of three veterans coming home with either TBI or PTSD, so there is a time lag in getting up to speed with the amount of mental health counselors needed.
All interviewed agree that some VA employees have a culture of being entrenched in their jobs without much in the way of accountability. Congressman Tom Rooney (R-FLA), an Army veteran and a member of the House Armed Services Committee, sees a simple solution, “One step the VA can take to ensure its employees better understand the difficulties our veterans face, and are more motivated to serve them, is to hire more veterans. The Department might also work to identify the best practices across the country and implement those successful policies at VA centers that are struggling. For example, I have personally worked across the aisle and with the VA to cut through some red tape and make it easier for TRICARE beneficiaries to see licensed mental health counselors,” which would double the number of mental health care providers for veterans.
A source from the House Committee on Veterans’ Affairs confirmed that among some of the 300,000 VA employees there is a culture of complacency. His solution is to stop transferring those poorly performing employees and managers to other offices, and instead “to remove them from the VA altogether. That is why last year, as part of the Honoring America’s Veterans and Caring for Camp Lejeune Families Act we passed legislation mandating regular training and assessment of VA employees in an attempt to bring more accountability to the system.” He also pointed out that in the last six years the VA’s mental health staff and budget have increased 40%; yet the significant increases did not result in significant performance outcomes. Also, the number of veterans waiting more than a year for benefits in 2009 was 11,000. Today it is 245,000, a 2,000 percent increase.
Even Jon Stewart is blasting the handling of Veterans’ benefits, “That is f—- criminal. The VA has a backlog of 900,000 people. McDonalds handles ten times that many customers in an hour, and may I remind you they are run by a clown.”
Colonel Sutherland sees a solution in a community-based approach. He noted that the VAs in Washington DC, Virginia, and Minnesota are very good in providing services. He also wants a “no wrong door” approach where every service and organization within the community knows the specialty of the others.
Debbie Lee agrees that there is definitely a need for a community-based point organization so a soldier does not have to do the research. She also supports the hiring of more vets to help the veterans, but suggests expanding the hiring process to families of vets as well, “The fire that burns in me is a passion that does not go out because I always see my son Marc, the first Navy SEAL killed in Iraq, and what he told me in his last letter, ‘pass on the kindness, the love, the precious gift of human life, through random acts of kindness.’ Who better to help, understand, and show compassion with passion than the family members.”
Debbie wants Americans to get involved by being voices for the troops still serving and to call for a reform of the VA system. The VA administrators, regarding the challenges and the solutions, will better serve veterans if there is a realistic approach to solving the problems at hand, or as Pete Hegseth stated, “Failure to plan is planning to fail.”