Following the sentencing of former nursing aide Reta Mays, West Virginia’s U.S. senators say hard work must be done to assure confidence in the Clarksburg veterans hospital where multiple patients died after being administered lethal doses of insulin.
Senator Joe Manchin, D-W.Va., says he is meeting Monday with Denis McDonough, secretary of the U.S. Department of Veterans Affairs.
“I want to make sure he understands the need to absolutely overhaul the management and the practices of the VA hospital,” Manchin said today.
Mays was sentenced to seven consecutive life terms in the deaths of eight veterans at the hospital in Clarksburg. Civil suits filed by families seek to hold the Department of Veterans Affairs responsible for even more deaths.
Mays admitted to killing veterans Robert Kozul, Robert Edge Sr., Archie Edgell, George Shaw, a patient identified only as W.A.H., Felix McDermott and Raymond Golden. She is also accused of administering insulin to “R.R.P.,” another patient who was not diabetic, with intent to kill him.
All had checked into the hospital to seek healthcare and all had expected to recover. None were being treated for diabetes, yet their blood sugar crashed under suspicious circumstances. Mays admitted causing their deaths by administering unnecessary and lethal doses of insulin while she worked the overnight shift.
MORE: Families describe loss as former VA hospital aide is sentenced to multiple life terms
Concurrently with the sentencing, the inspector general for the Veterans Administration released a scathing 100-page report concluding that, although Mays killed the veterans, the hospital and its leaders were responsible for the conditions allowing her actions.
“While responsibility for these criminal acts clearly lies with Ms. Mays, the OIG found inattention and missed opportunities at several junctures, which, if handled differently might have allowed earlier detection of Ms. Mays actions or possibly averted them altogether,” according to the report by the Office of Inspector General for Veterans Affairs.
Manchin said that’s a call to action.
“I had said before that I couldn’t get involved because of the investigation. Now with the report being done and the sentencing of Reta Mays we can go further, quicker and faster and make something happen and make the changes that need to be made,” Manchin said.
The inspector general’s report concluded that Mays’ earlier employment history meant she never should have been hired by the veterans hospital, which didn’t complete proper background checks. Allegations of excessive use of force were leveled against Mays while she worked as a corrections officer at the North Central Regional Jail.
And she also should not have had access to the insulin that caused fatal hypoglycemic episodes among the veterans. Medication rooms and carts were not properly secured on Ward 3 where Mays worked, the OIG report concluded, giving her unauthorized access.
“How in the world did they not know by doing a background check on Reta Mays that she should not be at that hospital, did not have the qualifications and had very poor recommendations for performance for other places she worked?” Manchin asked.
“How did they leave all the medicines on the carts unprotected?”
The inspector general’s report described some corrective actions by the facility — “to improve medication security, nursing policies and processes and general oversight.”
The report noted that cameras were installed to provide views of Ward 3A’s four hallways and entrance, and a motion-activated security camera was installed in the 3A medication room.
The Louis A. Johnson VA Medical Center released a statement this week expressing condolences to the families as well as gratitude for the inspector general’s investigation. The statement noted VA has reached financial settlements with a more than a half dozen families of veterans through the Federal Tort Claims Act.
During the OIG investigation, the statement contended, VA put in place safeguards to enhance patient safety, including medical chart audits, checks and balances within pharmacy quality assurance processes and quality management reviews.
“While this matter involving an isolated employee does not represent the quality health care tens of thousands of North Central West Virginia Veterans have come to expect from our facility, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future,” according to the statement.
Manchin was not impressed.
Speaking on MetroNews’ “Talkline,” the senator said “The whole statement you just read is pure BS. If they think they’ve corrected all that right now, I haven’t seen that correction.”
Michael Missal, the inspector general for the VA, said he hopes the Clarksburg VA and similar hospitals for veterans around the country will take the report to heart. He said some of the recommendations — such as underscoring hiring practices or properly securing medicine — were extended to hospital administrators even before the report was released.
“Do we inform VA? Absolutely. Our role is to help VA improve. Our role is to help veterans get the highest quality healthcare,” Missal said during a Wednesday morning roundtable interview with reporters from around the country. “We are going to immediately let VA know you have failings here.”
He continued, “If we found something that we thought needed to be changed to improve the quality of healthcare, the answer is yes.”
The inspector general emphasized that veterans hospitals need a culture that puts patients first. In this case, the inspector general concluded, that was deeply lacking with disastrous results.
“If that isn’t the culture promoted by leadership you will eventually get to shortcomings,” said Julie Kroviak, deputy assistant inspector general for healthcare inspections.
The VA announced last Christmas Eve that the hospital’s director, Glenn Snider Jr., would no longer serve in that role. Snider was reassigned and has been working at a regional office.
“Any type of personnel decision is really VA’s to make,” Missal said when reporters asked why Snider wasn’t fired.
The medical center’s top executive for nursing was also reassigned last Dec. 28.
Senator Shelley Moore Capito, R-W.Va., agreed that the inspector general’s report underscores major concerns.
“Reading this report is just devastating. The failures at the Clarksburg VAMC outlined within this report are absolutely unacceptable,” Capito stated.
“The findings show a collapse of administrative and clinical responsibility that has led to unimaginable consequences, which makes it clear that updated policy and procedure is desperately needed.”