"There is a systemic lack of oversight and inability to adhere to their own directives", Swigman Says.
The final report has not been released to the public, but News 4 received a copy exclusively from the union which was only able to obtain it through a public records request.
Among the findings in the report:
That the hospital is not providing pain management oversight for patients as required by the Veterans Health Administration.
The report recommends the hospital develop a plan to improve access to pain management services.
The VA says all requests for pain medication will now be addressed by a pain management panel within approved timelines. Those timelines can vary depending on the case.
The report also found that last summer, physical therapy was critically understaffed at the v-a hospital, causing delays for patients who were forced to obtain outpatient therapy services.
The report recommends the V-A develop and implement a comprehensive plan to account for staff fluctuations.
In response, the V-A says it has hired two additional physical therapists to improve staffing.
And in the Community Living Center, what is essentially a nursing home at the V-A, the O-M-I report found a lack of resident activities and an overall lack of physical activity for nearly all C-L-C residents and issued six recommendations to improve staffing.
" The reason why this concerns me, if you've got an older person who doesn't use their muscles they become deconditioned. Their muscles waste away," said Dr. Robert Mittan, a psychologist and steward for the union.
The V-A says it is addressing the issue at the Community Living Center by focusing more attention on developing specific plans for the therapeutic, physical and social needs of these patients.
The O-M-I report also found that one veteran who was battling cancer had his treatment unnecessarily delayed for 6 to 8 weeks after management requested a second opinion from an outside consultant. That patient later died when the cancer became inoperable. Though the report does not say the delay caused the veteran's death. The union, however, is convinced there is a connection.
"A delay of 6 to 8 weeks. Make your own conclusions," Jeanine Swigman told News 4.
The report recommends the hospital set a time standard when requesting care outside the V-A system and also discuss the reasons for the delay with the veterans family.
The V-A says a new time standard has been put into place when it comes to requests for care outside the v-a system. Again , those standards vary depending on the case.
News 4 contacted the Office of the Medical Inspector and the V-A Hospital, neither was willing to speak with us on camera about the report.
V-A spokesman Darin Farr told us the reason they won't is because of privacy concerns, and the fact that the report covers such a wide range of issues.
But the union doesn't buy that explanation.
"I think the facts are just too damning. And the V-A doesn't have an answer for this." said union president John Copeland.
In all there are 53 recommendations laid out in this report aimed at improving the quality of health care at the V-A hospital. Union members say they hope those recommendations are adopted by management. But they also say they feel the changes need to start at the top and say they say the next step is asking members of congress for help in getting that done.