Even as Dorn OR closes again, congressmen see improvements at VA hospital | Healthy SC | The State

The Dorn VA Medical Center has fixed its deadly gastroenterology backlog, but the chairman of the House Veterans’ Affairs Committee said Monday he is concerned officials haven’t suffered serious consequences.

Meanwhile, the hospital announced that its operating room has been shut down for the third time in recent months due to a perplexing ventilation problem.

After meeting with Dorn officials Monday, U.S. Rep. Jeff Miller, R-Fla., said the operating room situation is being dealt with properly, unlike the extended backlog in gastroenterology consults. Those delays and how Dorn officials dealt with them have “put a black mark on this facility that has had years of providing good quality health care for the veterans.”

A report last year from the Office of Inspector General found that almost 4,000 Dorn patients recommended for gastroenterology tests were waiting to be examined at one point in 2012. The delays have been associated with at least 52 cancer cases and six deaths, and at least nine families have filed lawsuits about the delays, according to the report and later testimony before Miller’s committee.

“They have gone a long way in solving the backlog issue,” Miller said. “What is unconscionable, I think, to anybody is that it got to the point that it got to. … And what’s amazing is that when they figured out that they had a problem and started focusing on it, it got worse. The numbers continued to grow.”

Eventually, the backlog was reduced by hiring more people and putting more resources on the problem, Dorn officials told Miller and fellow Republican U.S. Reps. Joe Wilson and Mick Mulvaney of South Carolina.

via Even as Dorn OR closes again, congressmen see improvements at VA hospital | Healthy SC | The State.

Congress demands answers after CNN report on VA deaths – CNN.com

(CNN) — Members of Congress traveled to two Veterans Administration hospitals featured in a CNN report to visit the facilities and demand answers about why U.S. veterans needlessly died there.

The congressional delegations led by Veterans Affairs Committee Chairman Jeff Miller, R-Florida, visited the Dorn Veterans Administration Medical Center in Columbia, South Carolina, and the Charlie Norwood Medical Facility in Augusta, Georgia, after a CNN investigation that reported patients died as a result of delayed or denied care.

Six deaths have been confirmed so far, and sources tell CNN the number of veterans who are dead or dying of cancer because they had to wait too long for diagnosis or treatment could be more than 20. Thousands of veterans were forced to wait months for simple screening tests like colonoscopies, and by the time they got diagnosed, it was too late.

Hospital delays are killing America’s war veterans

The wait lists for gastrointestinal appointments at the hospitals number in the thousands and go back as far as 2010. Both hospitals say the wait list issues have been resolved, but according to the visiting members of Congress, the VA still cannot explain why or who was responsible for the poor treatment of veterans.

Rep. John Barrow, a Georgia Democrat whose district includes the Charlie Norwood VA center, said Congress has “a duty to make sure that the veterans who serve get the best health care possible. And it is very obvious that for too long and for too many folks that hasn’t happened.”

Citing a lack of any disciplinary action and lack of ability to identify who at the VA caused the backlogs to exist, Barrow told reporters, “Our goal here today is to try to get to the bottom of what happened and to prevent this from ever happening again. What’s important (is for) folks to understand this is just one step of a multistage affair to get to the bottom of what happened and to hold accountable those who were responsible.”

The Veterans Affairs Committee has been looking into problems at VA medical centers for the past year and says the VA administration continues to stonewall and withhold information the congressmen believe is critical to understanding why the VA appears to be run so poorly. The VA has also refused CNN’s repeated requests to interview Secretary of Veterans Affairs Eric Shinseki or any other VA official on camera.

VA hospital apologizes for deaths

Miller said the practice at the VA seems to be to hold no one accountable for errors, and instead transfer poorly performing executives and employees to other facilities instead of firing them.

In an interview with CNN, Miller said he and his committee will continue to demand to know the names of those responsible and to demand disciplinary action. “That’s why we asked the question again today … tell us exactly who was disciplined and how.” Miller said, “I don’t want to hear the excuse anymore that it was, ‘well, it was multifaceted, there were many people involved.’… Well, if there were many people involved, then they all need to go.”

Miller, who said he has been reluctant to make his investigations political, did say it is time the White House starts paying attention to the deteriorating treatment of the nation’s veterans. He said he has been frustrated by a lack of cooperation from the Veterans Administration leadership, and that Shinseki has not paid enough attention to the medical problems at VA medical centers. Miller also said it is time President Obama pay as much attention to what is happening at VA medical centers as he does to what’s happening in Washington or Hawaii, a reference to the president’s recent vacation to his home state.

“It’s time for him (Shinseki) to show some passion. And certainly it’s time to show some passion from the President. I mean, the fact that we’ve had veterans who have died in the very facilities that are supposed to be taking care of them, and not by natural means, by means that could have been prevented, is egregious.”

The congressman said his group has given the VA 30 days to respond to their requests for those answers.

via Congress demands answers after CNN report on VA deaths – CNN.com.

Bad VA experience: Las Vegas veteran worries about next time | Las Vegas Review-Journal

Kenneth Van Eaton knows about saving lives.

As an infantry sergeant in the Vietnam War, he carried his radioman to the safety of a rescue helicopter after they were both wounded by a rocket-propelled grenade in 1968.

For his valiant efforts in combat during the war that claimed the lives of some 200 soldiers in his 1st Infantry Division units, he was awarded the Bronze Star and Purple Heart medals.

Flash forward 45 years. Now the 69-year-old Army draftee veteran is worried that the Department of Veterans Affairs Medical Center five minutes from his home in the north Las Vegas Valley won’t be able to save his life if he has a medical emergency, especially one involving his enlarged aorta artery.

From his observations, the emergency room is too busy and understaffed to handle the number of veterans seeking emergency care.

“If they take me there in an ambulance if I have a heart attack, they will send me to another hospital. If I die in transport, they will be liable,” he said about the VA Medical Center.

Van Eaton is one of dozens of veterans who have called or sent emails to the Review-Journal expressing concerns about long waits and mistreatment by staff at local VA facilities after a Nov. 27 story about blind, diabetic Navy veteran Sandi Niccum. She waited six hours Oct. 22 in pain at the VA Medical Center emergency room suffering from what private doctors at a Henderson hospital diagnosed three days later as a ruptured, abscessed colon and a large, unspecified mass on her abdomen. She died Nov. 15 at age 78.

Niccum’s case has prompted an inspector general’s investigation at the request of House Veterans Affairs Committee Chairman Rep. Jeff Miller, R-Fla.

Van Eaton’s concern stems from what VA paperwork shows was a nearly 11-hour experience at the center’s emergency room and pharmacy on Sept. 30 that Van Eaton says actually happened on Sept. 29 and 30 after his wife took him there for a non-life-threatening case of gout.

The flare-up caused his foot to swell and turn red. It was so painful, he couldn’t walk. “It was like someone was sticking a knife in my foot,” he said Monday.

After he checked in the emergency room at 1:30 that afternoon, he told a VA staff member that he had gout, based on a previous diagnosis by a private doctor.

“I thought it’s a simple thing. I’ve got gout. Give me some pills and I’ll go home,” he said.

Instead, he sat in the waiting room for two hours. Then he was put on a gurney and rolled to a hallway where he said he spent most of the next eight hours except for when he was given an ultrasound to check for blood clots and an X-ray for any broken bones. After the shift ended for the doctor who had ordered the tests, another doctor came out about 11 p.m. to tell him what he already knew: that he had gout.

A prescription was written for two medications — indomethacin and colchicine — and filled at the hospital pharmacy at 12:05 a.m. on Oct. 1, according to Van Eaton’s receipt from the pharmacy. His medical record shows he entered the emergency room at 1:30 p.m. with a discharge notation at 11:22 p.m. on Sept. 30.

On Tuesday, a VA spokesman said in an email that the emergency room discharge note “is not representative of when he was discharged.” The spokesman, Richard Beam, earlier had said he was told Van Eaton was discharged around 8 p.m., but he couldn’t immediately explain the four-hour gap that Van Eaton endured until his prescription was filled.

When asked about Van Eaton’s case on Friday, Beam wrote that he was triaged for the level of care he needed. “Any perceived delay in care was due to other patients needing more emergent attention.”

Van Eaton said the wait he experienced “was ridiculous.” He also found out this week that his regular appointments for health and psychiatric care — he’s rated 100 percent disabled for post-traumatic stress disorder — have been pushed back by months because of lack of staffing.

“I think they need a major overhaul,” he said.

Contact reporter Keith Rogers at krogers@reviewjournal.com or 702-383-0308. Follow him on Twitter @KeithRogers2.

via Bad VA experience: Las Vegas veteran worries about next time | Las Vegas Review-Journal.

Nurse’s Aide Accused of Stealing Crucifix from Dying Veteran | WNEP.com

PLAINS TOWNSHIP – Court records say a nurse’s aide from Lackawanna County is accused of stealing a gold chain with a crucifix off of the neck of a dying veteran in hospice care last month.

Authorities charged Warren Wells, 42, of Madison Township with robbery at an arraignment on Wednesday afternoon.

According to investigators, a 14K gold chain with a crucifix was reported missing from a patient inside the Department of Veterans Affairs Medical Center near Wilkes-Barre in December of 2013.

Court documents said army veteran Laurel Sywensky, 60, Lehigh County, died the following day, and the woman’s son suspected that a male employee seen outside the hospice care room had swiped the jewelry.

Police based at the hospital say that records from the Northeastern Pennsylvania Precious Metals Database showed that Wells sold the chain and crucifix at J.B. Jewelers in Scranton, within an hour after his shift was supposed to end on the day of the alleged robbery.

Court documents said Wells sold the jewelry for $100, but a jewelry store employee told police that the value was estimated at $360.

Veterans heading to appointments inside the medical center told Newswatch 16 that they were surprised and disgusted by the allegations.

“I had some valuables and they weren’t tampered. It kind of surprises me that something like that would happen,” said Chester Zeshonsk of Scranton.

“He has a lot of nerve to steal it, if he believed in that kind of religion,” said Don Melvin of Scranton.

One neighbor who lives near Wells’ home in Lackawanna County told Newswatch 16 that he was stunned by the arrest, and described the nurse’s aide as a “very religious man”.

via Nurse’s Aide Accused of Stealing Crucifix from Dying Veteran | WNEP.com.

VA hospital’s release of delirious veteran latest in string of failures – Washington Times

Doctors at a Veterans Affairs hospital in Puerto Rico released a patient who was suffering from delirium and barely able to function, ignoring evaluations by staff nurses, an investigation found — the latest in a string of high-profile incidents at the department’s medical facilities.

Officials discharged the man even though he could not take care of himself, was malnourished and dehydrated during his stay and required an ambulance ride to leave the hospital, according to a report by the agency’s inspector general’s office.

SEE ALSO: California bar owners fight city to keep pro-veteran sign

The man’s family brought him home to Arizona, where he was promptly admitted to another hospital.

Mistreatment of veterans by the VA medical system has drawn harsh criticism on Capitol Hill. Rep. Jeff Miller, Florida Republican and chairman of the House Veterans Affairs Committee, leads a delegation Monday to visit centers in Columbia, S.C., and Augusta, Ga., where lawmakers say nine veterans have died because of mistakes by the VA.

A death at a Jackson, Miss., facility prompted a congressional hearing in November.

“It is painfully obvious that VA is not taking the problems occurring at this facility seriously and is showing a lack of commitment that quite apparently affects care provided to veterans,” Rep. Mike Coffman, Colorado Republican, said at the hearing.

Investigators suspect as many as 21 veterans died because of mistakes and mistreatment at VA hospitals in the past year.

A December investigation by the Government Accountability Office, Congress‘ watchdog arm, found that hospitals in Dallas; Nashville, Tenn.; Seattle; and Augusta, Maine didn’t adhere to peer-review practices, which could mean little oversight of problems or unsafe behavior by doctors.

As for the man in Puerto Rico, the inspector general said, he was admitted to the hospital for surgery in September 2012 that likely was related to his chronic liver disease brought about by alcohol abuse. During his 54-day stay, he was treated for a urinary tract infection and pneumonia.

Investigators said the man was not properly treated during his stay. He was malnourished and dehydrated and dropped from a weight of 213.9 pounds right after his surgery to 117.5 pounds. The urinary tract infection was not cured and the man’s skin was covered with ulcers. Plus, he had begun to show signs of delirium.

“Nursing notes indicated the patient remained confused and combative, had visual hallucinations, and required intermittent restraints during the remainder of his hospitalization. They also noted the patient was unable to stand, perform self-care, or feed himself,” the inspector general said, quoting notes written 10 days before the patient was discharged.

A social worker told the patient’s family that he probably would need rehabilitation and more treatment once he left the hospital. The family traveled to Puerto Rico and flew with the man back to Arizona. He required an ambulance to transport him to the airport.

Once in Arizona, the man was admitted to a second VA hospital. The inspector general reported that he recovered and is now in a state home for veterans.

The report did not give specifics on the patient’s name or service, but said he is a veteran in his 40s who moved to Puerto Rico in December 2011.

via VA hospital’s release of delirious veteran latest in string of failures – Washington Times.

U.S. Sen. Casey: New VA chief needs integrity | TribLIVE

he Department of Veterans Affairs should appoint an experienced leader of “unquestioned, unassailable integrity” to shore up the Pittsburgh VA system because of the Legionnaires’ disease outbreak blamed for five deaths, U.S. Sen. Bob Casey said this week.

In a letter to a top VA health care administrator in Washington, Casey called for a regional director who won’t simply curb preventable deaths but will “bring a fresh vision” to invigorate Veterans Integrated Service Network 4. The North Shore-based service area known as VISN4 includes the beleaguered VA Pittsburgh Healthcare System and nine other VA medical centers in Pennsylvania, West Virginia and Delaware.

“Government agencies or offices are sometimes very difficult to motivate. Sometimes people want to do things the way they’ve always done it,” said Casey, D-Scranton, a former state auditor general and treasurer.

Casey urged VA Undersecretary for Health Robert A. Petzel to consider “the necessary leadership skills that were not present” during the two-year outbreak of Legionnaires’ disease at VA campuses in Oakland and O’Hara.

Federal reviewers found bacteria-tainted tap water sickened as many as 21 patients from February 2011 through November 2012, though a Tribune-Review investigation unearthed records of alarming Legionella bacteria levels as early as 2007.

The VISN4 director during the outbreak period, Michael E. Moreland, fell under intense scrutiny from lawmakers and victims’ families when an internal review found the Pittsburgh VA failed to control the Legionella. Moreland, whose salary in 2012 was $179,700, retired on Nov. 1. He could not be reached on Thursday.

His successor, Gary W. Devansky, is serving on an interim basis, VA officials in Washington have said. They would not say this week when a permanent director might be named, how many candidates they might consider, or whether any VA workers or administrators were disciplined because of the outbreak.

A public directory of Pittsburgh VA executives appears unchanged, listing Terry Gerigk Wolf as CEO.

The VA “is committed to selecting the best-qualified candidate for the VISN4 director in order to serve the veterans in our region,” national VA officials said in a statement from spokeswoman Ramona Joyce. “Our mission is to provide the high-quality, safe and effective health care that veterans have earned and deserve.”

On Capitol Hill, Rep. Jeff Miller condemned what he termed a failure “to hold employees and executives accountable for the outbreak.”

Joyce said the VA is “reviewing administrative actions” and would respond to lawmakers. The review process dates at least to November, when U.S. Attorney David Hickton announced prosecutors identified no criminal wrongdoing in the outbreak’s handling.

“It’s well past time for VA leadership at all levels to mount a serious effort to end the culture of complacency that is engulfing the Veterans Health Administration and compromising patient safety,” said Miller, a Florida Republican who chairs the House Committee on Veterans’ Affairs. “The only way VA can succeed in this task is by empowering leaders who are committed to accountability and getting rid of those who aren’t.”

Casey said Moreland’s successor should inspire workers by example and challenge “the VA to be fully committed to excellence.”

“They need to find a qualified person who is a veteran, who has served in the forces. I think they will treat veterans a whole lot different,” said Maureen Ciarolla of Monroeville, whose father, John J. Ciarolla, died in the outbreak. “Nobody is held responsible for this thing.”

via U.S. Sen. Casey: New VA chief needs integrity | TribLIVE.

VA doctor says Gulf War vets not getting effective treatments | The Leaf Chronicle — Clarksville, Tenn., and Fort Campbell | theleafchronicle.com

WASHINGTON — As Department of Veterans Affairs physicianNancy Klimas told an agency panel Tuesday about the many successful ways her clinic has been treating Gulf War illness, veterans have responded with a combination of hope and anger.

The hope came because her clinic appears to be making headway in using research-based methods to treat veterans with the disease, which consists of symptoms ranging from headaches to memory loss to chronic fatigue, and plagues one in four of the 697,000 veterans of the 1991 Persian Gulf War against Iraq.

The anger came because, although Klimas had been using at least some of her methods for a decade, none of them have been disseminated throughout the VA system for use in other clinics. Her testimony was part of the ongoing fight between Gulf War veterans, who believe the government is ignoring physical causes for their ailments, and the VA, which has been reluctant to support the veterans’ claims.

Klimas heads the Institute for Neuro Immune Medicine at Nova Southeastern University in Miami, and she leads Gulf War Illness research at the VA Medical Center in Miami. She said she has asked her patients to be their own advocates because many physicians don’t believe the illness is anything but psychiatric.

Others, Klimas said, don’t have time to read the training manual VA put out to help them care for Gulf War veterans, don’t have more than 15 minutes to deal with each patient, or don’t know how to refer them to specialty clinics where they can get care — and some simply don’t care to learn.

“That was a great presentation, but I can’t resist adding that this information has been in the hands of Dr. Klimas for 12 years,” said Jim Binns, chairman of the Research Advisory Committee on Gulf War Veterans’ Illnesses, which met with VA officials Tuesday.

For 23 years, Gulf War veterans have argued they were exposed to toxins, such as pesticides, insect repellents, anti-nerve agent pills and nerve agents that caused them to be sick. They’ve said they do not believe their ailments are due to stress because of the war’s short duration and because the majority of troops were not exposed to the fighting. But until 1997, the VA focused on psychological disorders and not research to determine physical causes for the ailments.

In 1997, Congress mandated Binns’ committee after a congressional report found that the efforts to find causes and treatments for Gulf War illness by government agencies were “irreparably flawed.”

Binns said Klimas’ use of research to create a plan to treat veterans is what should have happened at the top level.

Robert Jesse, the VA’s principal deputy undersecretary for health, said the agency was trying to develop a “medical home” program that would allow doctors to spend more time with specialty cases, such as those involving Gulf War illness.

“This is a wholesale change in how we’re approaching care in VA,” Jesse said.

Relations between the VA and Binns’ committee have long been contentious and worsened last year when VA Secretary Eric Shinseki signed a directive ending the panel’s independence and ruling that Binns’ term would end this year. The board’s budget was also reduced, and new members were appointed.

New members of the board were at Tuesday’s meeting.

Jesse said the “new membership is a good balance of veteran representatives and good science.”

Some veterans activists disagreed that progress had been made.

Julie Mock, who served as a dental hygienist in the war and was exposed to sarin gas released when the United States bombed a chemical factory, and who now suffers from Gulf War illness, said she feels the VA is violating Congress’ intent.

“There doesn’t seem to be any accountability,” she said after sitting in on the meeting. “Congress mandated this research, and now VA has reworked it to suit their needs.”

Binns said a House hearing last March in which a former VA epidemiologist claimed officials purposely hid or manipulated data to avoid paying Gulf War illness claims changed relations with the department.

“We had three years of positive change,” Binns said. “Then, abruptly, the wind shifted.”

via VA doctor says Gulf War vets not getting effective treatments | The Leaf Chronicle — Clarksville, Tenn., and Fort Campbell | theleafchronicle.com.

Veterans Affairs Police Chief Pleads Guilty In Manhattan Federal Court To Participating In Kidnapping Conspiracies

Meltz, Richard S5 Information12 Cr 847 Information

Former Veterans Affairs Police Chief Pleads Guilty In Manhattan Federal Court To Participating In Kidnapping Conspiracies

FOR IMMEDIATE RELEASE Thursday, January 16, 2014

Preet Bharara, United States Attorney for the Southern District of New York, announced that RICHARD MELTZ pled guilty today to charges arising from his involvement in two separate conspiracies to kidnap, rape, and murder specific women. MELTZ, at the time the Chief of Police, United States Department of Veterans Affairs, at the Bedford Veterans Affairs Medical Center, conspired to kidnap, rape, and murder the wife of a man he had met over the Internet, and a female Federal Bureau of Investigation (“FBI”) agent working in an undercover capacity. MELTZ was charged in April 2013 and pled guilty today before U.S. District Court Judge Paul G. Gardephe.

Manhattan U.S. Attorney Preet Bharara said: “Richard Meltz, a former law enforcement officer, now stands convicted of serious federal crimes for his involvement in two sadistic kidnapping, rape, and murder conspiracies. Prosecuting and bringing to justice perpetrators of such depraved and violent crimes is at the core of this Office’s mission. Meltz’s guilty plea today furthers that mission and brings us one step closer to resolving this case.”

According to the Information to which MELTZ pled guilty, statements made during the plea proceeding, and other court documents:

Between the spring of 2011 and January 2013, MELTZ, Robert Christopher Asch, and Michael Van Hise engaged in a series of electronic email and instant message communications during which they discussed and planned the kidnapping, torture, and murder of Van Hise’s wife and other members of Van Hise’s family. Van Hise sent to MELTZ and Asch photographs of these family members, and the approximate location of their residence. MELTZ engaged in detailed discussions about kidnapping and brutalizing the proposed victims, and ultimately assisted Van Hise and Asch in planning a kidnapping, rape, and murder. The co-conspirators ceased active planning of the kidnapping when the FBI arrested New York City Police Officer Gilberto Valle for a related kidnapping conspiracy, and began investigating Van Hise.

In addition, beginning in approximately January 2013, MELTZ, Asch, and an FBI agent working in an undercover capacity (“UC-1”) began discussions about kidnapping a woman, who unbeknownst to MELTZ and his co-conspirators, was also an FBI agent working in an undercover capacity. MELTZ participated in multiple conversations with both UC-1 and Asch about the conspiracy’s objective to kidnap and commit acts of violence against the intended victim and other women. He advised Asch to obtain a stun gun to subdue the intended target, and based on MELTZ’s direction, Asch purchased a high-voltage Taser gun at a gun show in Pennsylvania, which they intended to use in the commission of the kidnapping offense. Charges against the two alleged co-conspirators, Michael Van Hise and Robert Christopher Asch, remain pending, and they are scheduled to begin trial in early 2014.

*                      *                      *

MELTZ, 65, of Linden, New Jersey, pled guilty to two counts of engaging in a conspiracy to commit kidnapping. He faces a maximum sentence of 10 years in prison and is scheduled to be sentenced by Judge Gardephe on May 22, 2014, at 2:30 PM.

Mr. Bharara praised the investigative work of the FBI. He also thanked the Department of Veterans Affairs and the New Jersey State Police for their assistance in the investigation.

The case is being prosecuted by the Office’s Violent Crimes Unit. Assistant United States Attorneys Brooke E. Cucinella and Hadassa Waxman are in charge of the prosecution.

The charges against Van Hise and Asch are merely accusations, and those defendants are presumed innocent unless and until proven guilty.


via Former Veterans Affairs Police Chief Pleads Guilty In Manhattan Federal Court To Participating In Kidnapping Conspiracies.

Investigation turns to Charlie Norwood VA Medical Center’s chiefs of staff | The Augusta Chronicle

Investigation turns to Charlie Norwood VA Medical Center’s chiefs of staff | The Augusta Chronicle.

The House Committee on Veterans Affairs has expanded its investigation into the Charlie Norwood VA Medical Center to look more closely into two chiefs of staff, one of whom recently told the board’s chairman that he made supervisors aware of problems in the hospital’s gastrointestinal program years before they became public.

Dr. Michael Spencer, the chief of staff at the Augusta VA, told Rep. Jeff Miller, R-Fla., during a congressional oversight visit Jan. 6 that he had notified supervisors of certain issues but no actions were taken.

In light of the information, which was revealed in a letter sent this week to U.S. Secretary of Veterans Affairs Eric Shinseki, Miller has requested a copy of all minutes from meetings involving Spencer; Dr. Luke Stapleton, the former chief of staff; and Richard “Toby” Rose, the associate director.

The committee requested in September a copy of all performance reviews, pay bonuses and disciplinary actions filed since 2007 for the administration of former Director Rebecca Wiley. Parts of the request are just now being delivered.

“Given the nature of the ongoing investigation, we request delivery within 30 days of this letter,” Miller wrote Monday after cautioning VA staffers against destroying, modifying or moving any records.

The committee’s most recent request covers all meetings involving Spencer, Stapleton and Rose dating back to 2006, along with any e-mails or reports that Spencer kept to document the problems he encountered, the supervisors he notified and any corrective actions that were taken.

The letter only states that Spencer encountered problems at least 10 years ago. Pete Scovill, a spokesman for the Augusta VA, did not elaborate on the problems, but said the “medical center will provide all appropriate material to (Shinseki) as requested.”

Before becoming chief of staff in 2012, Spencer served as the head of primary care, the department in which the hospital’s delay of 5,100 gastrointestinal consultations reportedly began.

Between 2011 and July 2012, three cancer patients died and the conditions of four veterans worsened after the management failed to schedule primary physicians’ referrals for 4,500 patients in need of screening, surveillance and diagnostic endoscopies, according to VA reports.

An online newsletter for the Augusta VA dated Aug. 29, 2010, states that Stapleton, 61, became the chief of staff on July 5, 2010.

Today, the VA’s Web site lists him as an oncology doctor and says the former Army colonel of 26 years completed his residency at Fort Gordon’s Dwight D. Eisenhower Army Medical Center after graduating from the University of Tennessee in 1980.

Records kept by the state Composite Medical Board show that Spencer, 55, was licensed June 11, 1987, after graduating from the Medical College of Georgia in 1984.

Rep. Jeff Miller (center), the chairman of the House Committee on Veterans Affair, talks to Charlie Norwood VA Medical Center director Bob Hamilton and Chief of Staff Michael Spencer during a Jan. 6 congressional oversight visit to Augusta.

VA report details contributing factors that led to patient death last year – Columbia Daily Tribune | Columbia Missouri: Local News

VA report details contributing factors that led to patient death last year – Columbia Daily Tribune | Columbia Missouri: Local News.

Contributing factors that led to a 78-year-old man’s beating death at Truman Memorial Veterans’ Hospital last February included ineffective communication among staffers and between law enforcement agencies, “a sense of complacency” among some staff and a failure to provide a safe environment for the victim, according to a report by an administrative board of investigation for the Veterans Affairs Heartland Network.



The board’s report, which was included in materials released by the VA in response to a Freedom of Information Act request, details what happened at the hospital on and around Feb. 1, when Rudy Perez Jr. assaulted and killed Robert Hill of Warsaw, and what the hospital could do to prevent such an incident from happening again. The board made its determinations after interviews with 22 staffers involved and reviewing 45 documents, including competency files for the entire staff of the inpatient mental health unit, where the two men were at the time Hill was killed.

Perez, 34, a former Marine who didn’t serve overseas, first assaulted Hill on the afternoon of Feb. 1. They were separated, and after Hill was treated and brought back to the common area of the inpatient mental health unit, Perez, who also returned after calming down, jumped him again and beat Hill to death.

The board also included in its report a list of eight recommendations for the hospital, including revamping its psychiatric practice model. Nearly all of those have been implemented, hospital spokesman Stephen Gaither said.

Perez’s lawyer, David Tyson Smith, said his client was in the midst of a psychotic episode when the events began that eventually led to his admission to Truman. Sedalia police arrested Perez on Jan. 29 on suspicion of assaulting a neighbor, who suffered minor injuries. Perez was held in the Pettis County Jail for 24 hours.

On Jan. 31, Perez allegedly assaulted his parents on Highway 50 west of Sedalia, their hometown, as they were trying to take him to get treatment in Kansas City. When officers arrived, they saw Perez stripping naked and then dragging his mother into oncoming traffic. He told authorities that he thought his father was a demon and that his mother was a witch.

His parents declined to press charges. Perez’s father was treated at a Sedalia hospital and released.

Perez was charged Feb. 5, 2013, in Pettis County with two counts each of third-degree domestic assault and assault on a law enforcement officer as well as one count each of resisting arrest and second-degree assault for the events leading to his admission to Truman, according to online court records. Those charges were never adjudicated.

After the roadside attack, Perez was taken to Bothwell Regional Medical Center in Sedalia, where a Pettis County sheriff’s deputy petitioned a court for a 96-hour involuntary commitment. The request was approved, and Perez was taken that evening to Missouri Psychiatric Center, which is operated by University of Missouri Health Care.

A psychiatry resident at the center requested Perez be transferred to Truman. That request was approved by the on-call attending psychiatrist at Truman, according to the board’s report. Perez was transported to Truman about 10:40 p.m. by three security officers and one VA police officer took custody of him, according to the report.

The VA police officer “was not advised of any incidents which precipitated the 96-hour hold” on Perez, the report said, and “outside law enforcement agencies did not, as a routine procedure, provide information directly to police concerning police incidents occurring prior to transport of patients to the VA facility.”

Perez was admitted to Ward 2B, a locked 12-bed area at the inpatient mental health unit at 12:11 a.m. Feb. 1. A nurse made a note at 1:56 a.m. that Perez threatened to attack Hill should the elderly man enter his room, the report said. The nurse signed it at 7:25 a.m. and added to it at 8:47 a.m.

The day resident assigned to Perez had examined and interviewed him before a 9 a.m. team meeting at the inpatient mental health unit. The resident did not see outside reports about Perez or the nurse’s note about the threat because they did their record review before the nurse signed it, the report said. The note was inaccessible after the meeting. There was no talk about Perez’s previous aggression during the meeting.

A new attending psychiatrist was assigned to Perez on the day shift and had no experience with him. Perez’s attending physician that day had not seen him before the team meeting, the report said. Attending doctors supervise residents. Nowhere in the report’s findings does it note the transfer of information pertaining to Perez’s history of violence to either of his attending doctors on Feb. 1.

Perez’s mother, the report said, “had numerous conversations with the resident physician and other clinical staff” in which she told them she was concerned that he was off his medications.

Hill wandered into Perez’s room at 3:10 p.m., and Perez assaulted him. The pair was separated. Hill was taken to the emergency department and treated for non-life-threatening injuries to his face. Perez also was briefly isolated but returned to the common area after calming down.

Hill was brought back to the common area at 6:20 p.m., the report said, with a one-to-one sitter, an employee who observes patients from a moderate distance. Before Hill was brought back to the unit, the emergency department did not receive “any information or guidance concerning returning” him. His attending physician assumed he would not be taken back there, the report said, and requested that he be given a one-to-one sitter for safety if he was.

The sitter also was not told that Hill had been assaulted, the report said. Two minutes after Hill was returned to the mental health unit, escorted by the sitter and a VA police officer, Perez attacked him, hitting him with his fists as he knelt over him in the hallway. Hill was taken to University Hospital, where he died around 10:30 p.m.

All of this could have been avoided, Tyson Smith said.

“Mr. Perez should have been isolated,” he said. “He was put right back in the day room again, when Mr. Perez was in the middle of a psychotic episode. Clearly someone dropped the ball.”

The investigative board identified eight “contributing causes” of the incident: Ineffective hand-off communication related to a history of violence; lack of consistent, reliable communication between law enforcement agencies; reluctance to use restraint, seclusion and pharmacology; failure to provide a safe, alternate environment; model of physician coverage; mixed population of patients; complacency; and different philosophies on violent and disruptive behavior within the inpatient mental health staff.

To address those issues, Gaither said, Truman has taken measures to increase communication with other law enforcement entities, crafted new policies, sought to hire a new full-time attending psychiatrist, and started training staff on the prevention and management of disruptive behavior.

In regard to law enforcement, Gaither said there is now an emphasis on sharing information on patients. Truman Chief of Staff Lana Zerrer said her staff is working to be more involved with police on mental health training and sorting out jurisdictional issues.

Finding an attending psychiatrist has proven difficult, Gaither said. The report said Truman’s primary care model — which included attending psychiatry coverage instead of a dedicated psychiatrist — might have contributed to delays in evaluation of Perez and hampered a safe approach for Hill’s return to the unit after the assault.

Hiring an attending psychiatrist will be done as part of changing the practice model for how psychiatrists cover inpatient duties, as recommended in the report. So far, interim measures include notifying everyone at Truman when there is an assault or incident that would raise concern, he said. Roles of nurses and other inpatient staff have also been defined more clearly, Gaither said. Zerrer said so far, the changes have been effective.

“I’m very pleased with the way we’ve changed our inpatient practice model at this point, but we need another psychiatrist for sure,” Zerrer said.

Zerrer wrote the new policies with other staff members and oversaw the changes. She researched medical journals on assault risk in psychiatric settings to aid in the changes.

“When a patient comes in to a psychiatric unit, we look at things like if they’ve assaulted anyone recently, if they have active psychosis and if they’re on withdrawal from a substance” and give them a risk assessment score, Zerrer said.

A board was installed in the unit that lists all patients with their risk levels, Gaither said.

Part of the problem was that some of the medical staff members at Truman were unaware that restraining a patient was within protocol, Gaither said. The hospital has taken pride in reducing the number of incidents in which restraints are used, Gaither said, something done after a national outcry a few years ago on the topic. The new assault policy addresses the issue and makes it clear that restraints can be used when there is a clinical decision that deems them necessary, he said.

Lack of communication among staff was the main breakdown that led to Hill’s death, according to the report.

Now, doctors are required to notify and document communication between departments when a patient is moved to the inpatient unit. Nursing personnel also are required to have a safety plan in place for patients who have been assaulted when they return to the unit, Gaither said. If necessary, they will now transfer them to a different unit at Truman or another area hospital, Gaither said, or a different VA hospital in the Heartland Network, which includes Missouri, Kansas and parts of Arkansas, Illinois, Indiana and Kentucky.

If an assault takes place, all personnel who are responsible for the patients are now required to meet and discuss the safest option for the victim. The report said everyone involved “agreed there was no place to have” Hill “go after the first assault other than back to the ward.”

“It didn’t quite happen the way it should have happened, and we didn’t have this huddle in place at the time,” Zerrer said of what happened after Hill was beaten the first time.

Zerrer, however, defended her staff.

“When you know what the staff knew at the time of the incident, it’s debatable,” she said. “It’s hard to say they should have done anything differently.”

Training for all employees in assault prevention — something in which the report cited a “large gap in staff awareness” — is expected to be completed within the next couple of months, Gaither said.

All of the new policies and procedures have amounted to a “culture change,” Gaither said.

“The important thing here when we talk about a culture change, a culture change is an evolutionary process. … There are continuing activities that are being reinforced,” he said.

One of Hill’s sons, Chris, declined comment and referred questions to the family’s attorney, Sedalia-based Spencer Eisenmenger. Hill’s other son, Tim, and Eisenmenger did not return calls requesting comment.

Perez was charged with first-degree murder in Hill’s beating death. He was acquitted Sept. 23 when Boone County Circuit Judge Gary Oxenhandler accepted his plea of not guilty by reason of insanity after two psychiatric evaluations determined that Perez was “driven by psychosis.”

Perez was remanded to the custody of the state Department of Mental Health and remains at Biggs Forensic Unit, a 186-bed maximum security unit of Fulton State Hospital. Perez’s family is doing well, said Tyson Smith. So far, Perez’s response to treatment has been positive, he said.


“Mr. Perez more likely than not is going to return to society if he responds to treatment well,” Tyson Smith said.