The VA won’t comment on the case but says its employees are “empowered to advocate for veterans without fear of retaliation” and “strongly enforces those protections afforded by the Whistleblower Protection Act.”
The Mississippi whistleblowers’ allegations, said OSC spokeswoman Ann O’Hanlon, met the high “substantial likelihood” standard required by OSC to refer cases to the Secretary of Veterans Affairs, who is then required by law to conduct an investigation and report the findings back to OSC. The VA has completed its investigations into the first three cases described below; the fourth and fifth cases are currently under investigation by the VA. The five cases, O’Hanlon said, include:
• In 2009, in response to a whistleblower disclosure to OSC, the VA confirmed that “dirty, rust-stained instruments,” and other unsterilized medical equipment, were sent to VAMC clinics and operating rooms in violation of VA policy. The VA outlined a series of steps to correct longstanding problems within the VAMC Sterile Processing Department.
• In 2011, a whistleblower alleged that employees continued to follow incorrect procedures in the Sterile Processing Department, placing the safety of employees and patients at risk. The VA investigated and did not substantiate the allegations. However, OSC determined that the VA’s findings were unreasonable, in part because they were made without interviewing the whistleblower, who disputed much of the VA’s response.
• In 2011, a whistleblower disclosed that Jackson VAMC public affairs employees were told to issue false statements that mischaracterized the findings in the 2009 case involving unsterilized medical equipment. A VA investigation confirmed that the VAMC made inaccurate statements to the public and Congress. However, the VA concluded that the inaccurate statements were not intentional because VAMC management was never informed by the VA that violations were found in 2009. OSC determined that the VA’s findings were unreasonable, and the VA should have informed the VAMC about violations of agency policy.
• In 2012, a whistleblower alleged that chronic understaffing in the Primary Care Unit threatens patient safety. Specifically, the physician alleged that narcotics are prescribed to veterans by nurse practitioners who are not legally permitted to do so. Physicians are pressured to prescribe narcotics to veterans they have not seen. Veterans are routinely scheduled for appointment times when no physician is on duty, leaving patients to arrive at unstaffed clinics, only to be turned away. Nurse practitioners operate in the facility in violation of VA rules and state licensing requirements. And, inadequate physician staffing levels result in numerous fraudulently completed Medicare Home Health Certifications. On February 28, 2013, OSC referred this case to the VA Secretary for an investigation, which is pending.
• Lastly, in 2013, a whistleblower alleged that a VAMC radiologist failed to properly read thousands of radiology images, leading to missed diagnoses of serious, and in some cases, fatal illnesses. Court documents demonstrate that VAMC management was aware of this but did not take corrective action, including notifying the affected patients. On March 5, 2013, OSC referred this case to the VA Secretary for an investigation, which is pending.
“The VA whistleblowers raise serious questions about the ability of this facility to care for the veterans it serves,” Special Counsel Carolyn Lerner said. “We urge the VA to carefully investigate and take corrective action.”
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