What causes the poor quality of medical care at the VA?

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.”

The overlap

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.
After reading the New York and Denver reports, Hirsch said her concern wasn’t the incidents themselves as much as that the competency of the nurses hadn’t been documented or evaluated in a long time.  Had she been in charge, the findings would have caused her “to be really nervous and want to jump on it immediately,” she said.  www.propublica.org/article/va-nurses-scrutinized-after-patient-deaths-in-two-states/single”><meta name=”syndication-source” content=”http://www.propublica.org/article/va-nurses-scrutinized-after-patient-deaths-in-two-states/single”><script type=”text/javascript” src=”http://pixel.propublica.org/pixel.js” async></script>

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

 

 

More at 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.

More at

 

The VA: a Culture of Disconnect

 

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.”

14 thoughts on “What causes the poor quality of medical care at the VA?

  1. After what is being done to me, I know there has to be more drug screening for Doctors and all staff, it might help with all the wrongful actions that occur in the Veterans Affairs. I’ve been hurt more recieving treatment then on my tour in the ARMY and watching other Veteran being treated the same way, were is the justice or is it just us. I was trained soldiers must look out for each other I will speek up and hurt mentally more mind games being played

    • I have a similar story. I was screwed over by a junkie surgeon in Boston. My care suffers since I complained and recommended drug screaning of surgeons. The doctor who ruined me is now working and nothing about his drug abuse is on line. My attempts to contact the IG at the va was a disaster; my care gets worse. We deserve better. The va set up a pill mill too cover up this doctors. The Doctor who set up the pill mill lost his license but the surgeon and his procter are still working.

    • VA Health is a joke my story:
      my name is Alan Lumpkin I suffer from High Blood Pressure, Corroded Artery Disease, and Permanent Nerve Damage in my back. I take several different meds.

      I have suffered terrible abuse and neglect at the hands of Bham VA Hospital in the past and have kept my mouth shut because of fear of having meds taken away, but since that has happened I feel Free to Speak Now. This report only deals with the last incident, I will address the others as my health allows. I am suffering withdrawal pains from opiates at this time.

      This report deals with the abuses done to me since my regular Doctor visit in April 2014
      I called to find out about my morphine and codeine subscriptions. I talked to Nurse Jennifer, she lied to me and misled me. I ask about my prescriptions. She informed me” I failed drug test, and the pharmacy canceled my refills. She instructed me to call the pharmacy that Anniston/Oxford Clinic did not cancel or have anything to do with my prescriptions” ( I must have been miss lead to believing they were my care givers not the Pharmacy). After calling the pharmacy I was told they had nothing to do with that and I needed to call my care provider. After calling back the nurse agued with me still insisting the pharmacy until finally she told me my doctor submitted cancelation on my Prescriptions. Ask did I want appointment: I said yes and was hung up on. Call back and Nurse was rude but finally gave appoint.

      I was not informed that I had failed Drug Test. the day of my doctor’s appointment in April till I called or anytime until my inquires by anyone at this facility or Bham. I deny using cannabis at any time in the 10 years I have been on Morphine and Codeine. I have never failed before in 10 years. I have issues with the chain of command on the test. I have taken mine home in the past with permission from the lab tech., was told just have it back by 2pm. The samples are not sealed and access is to anyone who wants it. There is no way I failed. Mute point at this current time since I am in the midst of Morphine and Codeine withdraws.

      At this point I am left to withdraw off Morphine and Codeine on my own after 10 years of use. As painful and challenging it is to try and put the events in order I may leave something out. I am already started suffering withdrawals and pray I do not have a seizure. I have advance notice of the withdrawal Pain and suffering. I have this because VA has screwed up my prescription several times. At one time this Anniston/ Oxford Clinic could not send my order to Bham correctly. I had to come to their office and pickup the prescription for many months and hand deliver to pharmacy in Bham. That is just a sample of the treatment given at this Facility.
      I have a back injury Nerve Damage that will be rearing its ugly head as soon as the medication is out of my system. I will be in constant pain that I would not wish on any human life. I will be unable to sleep because of the nagging pain that never stops.

      My Doctor failed in his duty to do me no harm. He also did me no good. I was not informed of discontinued use of narcotics. I was not offered a new test; I was not prescribed anything to help with the withdrawal process that I am currently involved with. I do not know if you or my doctor knows what withdrawal from morphine after 10 years is like. Let’s just say it will not kill a healthy person but it will make them wish they were dead. I am not a healthy person due to a back injury and Carotid Artery Disease. I am also holding VA responsible for any ill that befalls me due to the withdrawl from morphine after 10 years of use and the pain I will endure from my nerve damage.

      I have been treated as a second class citizen by the VA. I take offence that I am even tested for drugs when the rest of the population is not. I was not offered anything, rehab, and no treatment of any kind. I also feel I should have been given the opportunity to challenge the findings from drug test and given another test at the time of my doctor visit. I was not even told.
      Since writing the above on Wed. 5/6/14.
      They made an appointment for me the next day. I arrived 30 min. early thinking I would be retested or be prescribed medication for the withdrawal process. The first person I saw was the lady that weights me, temp and blood pressure (my blood pressure was high). She proceeded to show me the test results and tell me that she failed to tell me at my last appoint. I do not believe this person is the soul person responsible for the troubles I am having with my care providers,
      At that visit I was told the VA wants everyone off narcotics and will be treating pain with rubbing and massaging per the seminars care providers are being given. The VA has set pain management back to the 1500s.
      I waited for over an 1 hour 15 min. to see Doctor with only 2 or 3 people in the whole place. As I sat and waited I saw the Person that comes to pick up lab work to take to Bham. At that point I was thinking no Drug Screen My heart shank to my stomach.
      I finally was call by my Doctor Guzman, by this point I only had 2 questions. 1. Was I going to be allowed to have a drug screen (pi in the cup)today. I ask my Doctor Guzman if I was and was told NO. Question#2 Are you going to give me anything for detoxing off 10 years of morphine use. The answer was NO. At that point I had nothing else to do but walkout and inform You I know longer will see Doctor Guzman whom has caused me more pain and suffering than I deserve.
      Please help me get another Doctor, I no longer have any faith in Dr. Guzman to do the best for my health. At this time I would like to file official complaints against, Doctor Guzman, Nurse Jennifer of the Anniston/Oxford Clinic
      As a post script I give you step by step of my last regular Dr. visit in April.
      My Doctor asks how I was and I told him good. From that point on my Doctor and I did nothing but have conversation about his journey from leaving this facility to work at Fort Rucker and his journey back to Oxford Clinic. Dr. Guzman never listen to my heart, my lungs nothing, he did absolutely nothing. He did not check anything. I ask for something for dry skin and craps he wrote prescriptions.

      All previous statements are sworn to be true. There is documentation for all statements made. If I rambled it is the withdrawals.
      Copies to:
      Dr. Guzman, Nurse Jennifer, Oxford Anniston Clinic, Bham Patient Advocate, Joint Commission’s Office of Quality Monitoring and VA Office of the Inspector General.
      Signed By My Hand on this the 8th of May 2014
      Alan Lumpkin Last 4 SS -4186

    • 12 thoughts on “What causes the poor quality of medical care at the VA?”

      I gave 2 reasons recently to Chairman Miller House VAC
      (June 26,2014)
      One reason is because many FTCA settlements are not reported to the NPDB (National Practitioners Data Bank).
      I won FTCA for wrongful death of my husband and gave Congressman Miller
      details on that.The settlement involved multiple doctors who caused my husband;’s death.They were Never reported to the NPDB.
      Another reason is that Section 1151,38 USC awards and the doctors who cause them ,are reported to No one.
      In both cases above,by a lack of reporting,or disciplinary actions, it means VA doctors can continue to be negligent with other veterans, and in FTCA situations, if not reported to the NPDB, they still maintain full credentialing privileges and get by scot free, although they have harmed or killed a veteran.
      I am an unusual VA claimant in that I recovered my FTCA offset from my DIC by then proving they killed a AO veteran,(my husband) with 2 AO presumptives,that were 2 of the disabilities they malpracticed on

      So between the 1151 DIC I received and the 100% under 1151 another vet I helped locally receive (same hospital) that is at least a half million there in 1151 negligence compensation, and will never show up in the US Treasury accounts under FTCA settlements and none of the doctors ever got reported or disciplined for their actions.

      Past GAO reports mentioned reporting failures by VA of the NPDB mandate many times,.and nothing was done about it.

      Maybe this time due to Phoenix, we might find out have many vets the VA really has harmed or killed.

  2. VA Loma Linda, CA has falsely imprisoned my 86 year old dad. They keep him drugged and deny family visits. I have had to hire an attorney. Warning: Keep away from VA hospitals. They neglect, abuse and contract out veterans to private entities who seize all their assets in return for kick backs.

  3. Most people would be surprised to know that VA actively recruits doctors who have been sued for malpractice and can no longer afford medical malpractice insurance. They have an entire program dedicated to searching for and alerting such bad doctors that the VA will accept them with open arms. Anyone can file a FOIA request and obtain the VA Central Office records that define and reveal this pernicious program that only serves to impose bad doctors on unknowing veterans.

  4. Not all doctors at Va suck. There are great docs who are treated so poorly by bozo administrators who are corrupt, not accountable get away with unbelievable crap that make the good doctors want to leave. That is what Northport Va is all about.The bureaucracy is unbearable and I truly feel sorry for veterans. Its all window dressing, Administrators care only for their performance bonuses and truthfully could not care less for the veteran. Its a business. Those who work hard work harder those who are inept get promoted and all the idiots support each other with no recourse. If you have the courage to speak up, you are considered a trouble maker.. its all so horrific.

  5. At Loma Linda VA, like so many others across the country they is a daily deluge of patients in need of care. Some medical personnel are caring, compassionate and very kind in administering to the veteran’s needs whereas there are others that are lacking. There is absolutely no room in the medical community for any “indifference” regardless if it is a VA facility or the private sector. My husband sought care at Loma Linda VA, in 2011, for multiple, serious health issues, some of which were terminal. The one the VA Administration deemed made him “incompetent” due to “dementia” as per the medical records supplied at the time of his application for medical benefits and disability pension, which was granted, was NEVER mentioned or addressed by anyone until I finally insisted his primary physician either write a consult or do something about it. A PET scan was performed confirming his diagnosis. He recently turned 59 years of age, so this is considered early onset of dementia. For the past 1 1/2 years I have written letters to the Director, Chief of Staff, Chief’s of two involved specialty clinics to sit with me, so as we could all “get on the same page”, to ensure he receives the care he needs and which is warranted. After not receiving any response, I made numerous phone calls whereas finally I spoke with Washington and Regional Counsel, who finally was able to schedule an appointment to sit with a new Patient Advocate, the new Director, Chief of Staff and Regional Counsel. First, thing I am told is they do not have any of my husband’s medical records, over 800+ pages, that I hand walked in and handed over to the primary he was initially assigned to to be scanned into the VA system. Immediately I am blown away, thinking this is an excuse for plausible deniability, of any and/or all claims of substandard treatment, yet…this VA “treated”, performed procedures and prescribed multiple medications since 4/2011! No court is going to accept “ignorance is bliss” as an acceptable defense not to mention compromising a patients right to privacy being violate, if they lost these records. Going through his VA medical records, which I urge every veteran to do, I found entries from several physicians, early on in their treatment of my husband, reference seeing “imaging and medical records provided by the patient, from the outside” which totally negates the Chief of Staff’s opening comment! Ignoring my requests for a meeting, not taking accountability, providing substandard care, ignoring and/or delaying a patient’s treatment or diagnosis, is not going to deter me as it might with others who become frustrated and disgusted and seek treatment outside the VA….as I informed them, “you do not know me, who I know, what resources I can use or what I am capable of doing. You have merely fueled my passion, which is now become my mission to make sure you do right by my husband, for as his guardian it is my responsibility to act, make decisions and speak up on his behalf. I am his best advocate”. I suggest anyone veteran using the services at the VA in Loma Linda, who have encountered any problems, not to give up…keep calling, keep making your voice heard, for if those in a position of authority are not made aware of the problems that you are experiencing, then how can one expect changes to be made? Contact your Congressman, Senator and let them know the problems you have with the VA…they too can not effect changes unless they are aware. Since there appears to be serious issues at hand, from coast to coast…change is not a luxury any veteran can afford to wait to transpire. They certainly do not want to see me grace their offices with a death certificate in one and autopsy report in the other!

  6. why are there so few “Veterans” working at the desk and clinics in the VA. the attitudes at some of the desk are border line criminal. “Residents”, i assume, in Dallas VA more concerned with cosmetic surgery than handling the medical issue presented 18 months – kidney stone – still got! dental plates that take 8 – 12 months to complete (vs same day at civilian facility). the last 3 – 4 years at the dallas VA has gotten so bad its frightening to go there for any treatment, other than general check ups with primary care. (my primary is exceptional). had a technician (not nurse or Dr) schedule me for pacemaker surgery./ refused, made appointment with cardologist, abnd only needed to adjust meds. IG complaints are referred to the patient advocate, who so far has ignored three written complaints, and doesn’t even attempt to solve anything if you walk in the office. if you use Dallas or Ft. Worth, you better have a back up plan.

  7. I am a well known veterans claims advocate.
    ( at www,hadit.com)
    In 1994 the VA killed my husband and I settled under FTCA in 1997.
    I have been round and round with OGC on this point…
    The VA violates the mandate of the NPDB (National Practitioners Data Bank)
    I was told the negligent doctors in my husband’s case, were too numerous to adhere to the mandate.

    A response I got from OGC Bradshaw the other day says the reporting is to come from the VHA, not OGC.

    How does VHA know what to report…I called the VISN director here in NY long ago and he was startled that he had no knowldge at all about my husband’s death which occurred diue to malpractice at the Bath VAMC in NY and then they tried to cover it all up at the Syracuse VAMC.

    OLMA has been useless in getting me any answers and VA ever tried to tell me a Perer review report that caused the RC to weant to settlement with me in mere months after4 getting my SF 95, NEVER EXISTED.

    I won my FTCA and 1151 without it but found it at the bottom of my C file ten years after the fact.

    There is a secret list at the OGC in DC. I know that fact because I am on it.
    I wonder how many others are on it…..
    successful FTCA claimants whose settlements were not reported to NPDB and thus, those doctors went on to malpractice on other veterans.

    Obviously a good reason to report them.

    I brought this up with the IG recently because I stiill have questions that VA has never answered.as to the proper FTCA settlement reporting requirements.

    I also feel the regional office here in Buffalo has suddenly destr\oyed 2 claims I had pending and on wortking on a claim I filed in 1995 and won under 3 bases already…

    I suggested to IG, who will get that DIC?
    I already get DIC. ( one check)

    1151 DIC 1998
    direct SC death due to undiagnosed and treated DMII due to AO 2010 and
    DIC due to undiagnosed and treated AO IHD (Nehmer) 2012.

    • Just to add…

      I feel my claims situation ( 2 claims I filed in 2012 and acknowledged as received)suddenly dont exist and the claim they are working on i( a moot DIC issue) is due to the fact that I gave testimony to the H VAC during Shreddergate, still available on line, and I have asked too many questions over the years that VA cannot answer.

      If the director of the Buffalo VARO has been getting bonuses she better give them back.

      There are more secret lists that we hardcore claimants ever dreamed of,in my opinion.

      I have done many radio shows with lawyers who help vets over the last ten years….. 2 of them were shocked at what I told them ,in preparing for these shows.

      Section 1151 awards have NO follow thorough at all.

      They dont get reporteed to the NPDB unless an settlement under FTCA occurred prompting the 1151 award.

      The BAth VA almost ki8lled another vet I know. We discussed the FTCA offset and he only wanted to file the 1151 claim.

      I prepared it for him and 100% P & T was awarded in mere months to him under 1151.

      The doctors who almost killed him ( probably some of the same ones here in NY who killed my husband ,only months before I wrote this other vets 1151 claim
      received no disciplinary action at all.

      In that respect Section 1151, 38 USC has to be tightened up because those successful 1151 awards,without FTCA filings, also are on a secret list…not at the Office of General Counsel,
      those secret lists are at every VA Regional Office.

  8. I turned in the Health Techs. for Cardiac Monitoring Patient Neglection to the OIG, They were cleared and I never got to be interviewed still to this day. Director Jeff Gerwing and Julie Azurin black bald me at the San Diego V.A in Ca. If I get sick I can’t crictal care help there and I’m a Federal Employee on leave without pay, a Patient and most of all a Veteran, what should I do.

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