Some VA Hospitals In Shocking Shape

Some VA Hospitals In
Shocking Shape – April 9, 2004

Fourteen years ago, an ABCNEWS hidden-camera investigation ignited a
firestorm about conditions and competence inside Veterans
Administration hospitals.
Recently, there have been new
stories of misdiagnosis, disastrous management and deficient care at
some of the nation’s 162 facilities.
At a hospital near
Cleveland, an ABCNEWS hidden-camera investigation found bathrooms
filthy with what appeared to be human excrement. Supply cabinets were
in disarray, with dirty linens from some patients mixed in with clean
supplies, or left in hallways on gurneys.
At a neighboring
facility, examining tables had dried blood and medications still on
them. In several areas, open bio-hazardous waste cans were spilling
over. Primetime obtained internal memos documenting that the equipment
used to sterilize surgical instruments had broken down – causing
surgical delays and possible infection risks.

With 130,000 young American men and women putting their lives at
risk in Iraq today, these conditions are particularly relevant. While
current soldiers are treated in military hospitals, when they leave the
service and need treatment, many will seek care at Veterans Affairs (as
the Veterans Administration is now known) hospitals.
you come back to be a veteran, it’s like a black hole, you know –
nothing," former Army Sgt. Vannessa Turner told ABCNEWS.
was stricken with a mysterious illness while on duty in Iraq this past
year. She retired from the military on medical grounds, and when she
reported to a VA hospital for treatment, doctors scheduled her for an
appointment six months later.

Not a Point of

who responded to a survey by the American Legion in 2003 said it
took an average of seven months to get a first appointment at a VA
hospital. In some hospitals, patients have waited as long as two years.

In 1999, Jack
Christensen, a former army sergeant who served in the Korean War, was
admitted to the VA hospital in Temple, Texas, with pneumonia, and ended
up staying three years.

Christensen’s wife, Pat, says the attitude of some of the
practical nurses was shocking. Some
of the patients were forced to beg for food and water, she says.

Instead of helping her husband go to the bathroom, she said, "they
would put a towel under his hips and tell him to use the towel."
Christensen said her husband’s condition worsened over several months –
so badly that at one point he developed horrific bedsores and dangerous
infections, and she says his doctors said they would have to amputate
his legs.

Pat moved her husband to a private facility, where his infection
healed and he underwent extensive physical therapy. She
sued the VA, and then used the money to pay for private care for her
husband. The VA denied liability but paid a settlement.

Dr. Jonathan Perlin, the deputy undersecretary for health, said the VA
system has sophisticated quality control. But when he was shown
ABCNEWS’ hidden-camera video of hallways and supply closets in
disarray, he said, "This is something we’re not proud of."


have long charged that the VA system puts patients on a kind of
assembly line, passing them from doctor to doctor.
There’s also criticism of
how the VA uses residents – doctors still training and not certified in
their specialties.

Soles served in the Navy during the Vietnam War. His wife, Denise, says
he was one casualty of this practice. In 1998, he went to the VA
hospital in Cleveland complaining of pain and diarrhea, and doctors
removed small cancerous growths from his stomach and esophagus.

But as his symptoms persisted over the next two years, his wife says
the VA gave him painful tests and repeatedly lost the results. His wife
says Soles was seen by a parade of constantly rotating resident
doctors, and there was little consistency in his care.

Soles was prepped for surgery but before the operation the doctors who
were present couldn’t agree on what they were going to do, she said.

Before he got sick, the 6-foot Soles weighed more than 200 pounds.
By the time his family finally decided to take him to a private
hospital, he weighed 80 pounds. Some VA doctors thought his problem
was psychosomatic.

When he could no longer recognize his own son, Soles was rushed to a
private hospital. There, Soles learned he was "a total mass of cancer
from his trachea to his renal bowel. And that there was nothing that
could be done," his wife says. Terry Soles died three days later.

The VA’s Perlin said the Soles story was tragic, but added:
"However, that is not the experience of most of the veterans who come
to us for care. … We take care of 7 million veterans. While the
majority of care is good, in a big system, bad things happen."

Whose Fault?

Critics charge that one of the big problems facing the VA is that
too much money goes toward administration, at the cost of nursing and
patient care.

Dean Billik, the former director
of the VA in Charleston, S.C., is brought up as an example.

In 1996, he was denounced for allegedly spending about $200,000 in
taxpayer money to redecorate his office; $1.5 million to renovate a
nursing home unit that stayed empty for two years; and tens of
thousands of dollars for a fish tank in the lobby – while there were
budget shortfalls and staff cutbacks were contemplated.
heard testimony claiming Billik was "blatant in his mismanagement," and
an inspector general’s report confirmed several of the numerous
allegations against him.
But after everything was brought to
light, Billik still got a bigger job: He was put in charge of the
third-largest hospital system in the VA, encompassing eight cities, 295
acres of land and 83 buildings. And his salary immediately jumped about
Primetime obtained budget information on the central Texas VA
system for Billik’s six-year tenure at the top. It confirms that Billik cut spending $2
million for the people in direct patient care – nurses aides and
practical nurses.

documents obtained by Primetime show that $129 million was spent on
construction at three of six facilities in Temple, Texas.

One source says Billik spent $1.8 million renovating a building at
Temple for his own offices – after it had been renovated for patient

Furthermore, Nancy Kelsey, who was a nurse at one of the Temple
facilities under Billik’s supervision, says the
way some of the staff treated patients was alarming. She says IVs ran
out, patients were neglected and dressings weren’t changed.

Melba Bell, whose husband,
Ed, served in Korea, said the staff was often idle and it would often
take hours to get help. Other families said that if patients or their
families persisted in asking for help, some of the staff retaliated.

At one point, Bell’s infection got so bad that the hospital used
maggots to try to eat away the decay. That’s not unusual treatment, but
what happened afterward was.

"The dressing that they had on there was real poorly done," said
Bell’s granddaughter, Chesney Shirmer. "Some of the maggots got out and
they were in the bed with him, you know? He could feel them in the

Ed Bell died of gangrene in the VA
hospital in 2002.

One More
confronted with these details, Perlin said he shared the outrage and
promised to look into fixing these things.
But there is one more problem. Many whistle-blowers and critics say if
you try to expose the truth, VA managers don’t want to hear it.

Charles Steinert, who worked for Billik in Charleston, says he felt
pressure to leave after he complained about some of the building
projects and how he was being treated by supervisors.
Melissa Craven, who also worked at the Charleston VA, says she suffered
retribution for two years after spoke out about some of her
Perlin said
it is easy for patients and their loved ones to lodge complaints about
VA care. "That’s important to us, because if there are concerns, we
want to address them," he said.

But many patients and their
loved ones told ABCNEWS that wasn’t their experience – and even worse,
many of the families are afraid to speak out.

"They’re afraid to say what really goes on, because they’re afraid
any little benefits that they have are going to be taken away from
them," said Denise Soles.


The day after Primetime presented its findings to the VA’s Perlin,
he ordered inspections of the facilities Primetime investigated.
found a number of problems at the Temple, Texas, VA, including poor
hygiene, insufficient staffing and low satisfaction among patients and
their families.

The VA announced it would bring in new supervisors, reassign some
personnel, train others, and begin recruiting additional staff.

Inspectors who went to the VA in Cleveland said it was in good
condition. However, after their visit, Primetime received phone calls
from several sources saying that the hospital had advance warning of
the so-called surprise inspection.
to those patients who accuse the VA of assembly-line care – that
patients go through a succession of doctors – a public relations
officer for the VA said it tries to ensure continuity of care, but that
may not always be possible.

As for Dean Billik, he has
now retired. In a phone conversation on Wednesday, he said he disagreed
with the VA inspectors, saying their report was "an opinion."

Billik said he relied on his staff to supervise nursing and recommend
budgets, and if he had renovated some buildings that then were closed
it was because he didn’t possess 20/20 hindsigh and made the best
decisions at the time.

Rep. Ted Strickland, a member of the House Veterans Affairs Committee,
called for the White House and Congress to approve enough money to
ensure that veterans get the care they deserve.

It’s a "situation that’s
crying out for change," the Ohio Democrat said after viewing
Primetime’s tapes.

Veterans and their families agree they deserve better. "They were
good enough to go fight for their country," said Melba Bell. "They
deserve to have the best treatment that they could get."

Denise Soles says that before
her husband died he asked just one thing of her: to speak out.

She said Terry Soles told her, "If we can help one other veteran
from going through the hell … That’s what we have to do."

Marie Buchanan

Researcher, Pastor-Assistant,


Veterans Medical Malpractice Claims: What You Should Know

Medical Malpractice Claims: What You Should Know
you are a veteran and you or family members were injured due to the
negligence of a doctor or other medical personnel at a VA hospital, you
may sue the U.S. government under a federal law called the Federal
Torts Claims Act (FTCA)

FTCA is broad and allows lawsuits against the U.S. government for a
variety of claims, including medical malpractice, but the requirements
for filing suit can be complicated. Before you (or your dependent) can
sue, you have to make an administrative claim against the VA for the
full amount of damages you have suffered. This claim can be made on a
Standard Form 95 that is available from government agencies and U.S.
Attorney offices. You could file this on your own, but you should think
carefully before doing that. You will never be able to ask for more
damages than the amount you put on the form unless you can prove that
the additional damages are based on evidence you couldn’t have known at
the time you filed your administrative claim. For this reason, you need
to know the amount of damages you might be entitled to receive, and you
usually need an experienced medical malpractice lawyer to tell you
that. If you write in a smaller damage amount on the form, you lose
your right to the rest forever.
your administrative claim is filed, the VA has 6 months to review and
investigate the claim. It may then either accept the claim and pay it
out in full, settle the claim for less, or reject the claim outright.
If the VA rejects your claim, you may file a lawsuit in federal court
to pursue the matter further. If the VA does nothing and 6 months goes
by, this will be interpreted as a rejection of the claim.

you wind up in federal court, you will sue under the FTCA. Overall, the
FTCA allows you to file a lawsuit within 2 years of discovering your
injury and what caused it. But given the 6-month time period needed to
file and complete your administrative claim, you really only have a
little over a year at most to begin taking action on your FTCA claim
(and the federal court will dismiss your claim if you try to file it
before your administrative claim period is done). So don’t
procrastinate! These legal deadlines are very tricky and it is highly
advised you consult an attorney experienced in VA medical malpractice
to protect your claim and possible recovery. If you miss a deadline,
you could lose your right to recover for the injury forever.

To find an experienced VA medical malpractice attorney, post
your case to the free Case
Evaluation Form
After posting your case, an experienced law firm that handles VA
medical malpractice cases will contact you for a free case evaluation,
without any cost or obligation.

For more information about the declining standard of care in
VA hospitals, see Veterans
Administration Hospitals
: Do They Measure Up to an Appropriate
Standard of Care?

Marie Buchanan

Researcher, Pastor-Assistant,

Veterans Administration Hospitals: Do They Measure Up to an Appropriate Standard of Care?

Administration Hospitals: Do They Measure Up to an Appropriate Standard
of Care?
Veterans’ groups
and others are raising concerns about conditions in Veteran
Administration (VA) hospitals. Official VA

have revealed unhealthy conditions like reused objects that can spread
infection, inadequate cleaning, and vermin infestations. Inspectors
have also found that staff members are not adequately supervised and
there is a high rate of adverse effects from medication. In the Durham,
North Carolina facility, the staff falsified reports
to show that defibrillators—essential life-saving equipment—were
routinely checked, when, in fact, the equipment was not adequately
maintained. <

The inspections
have found even more serious violations in the way resident physicians
are supervised. Inspectors had difficulty locating supervising
physicians in four VA facilities who were supposed to be present to
oversee residents and found many other irregularities. In Lexington,
found that supervising physicians gave their computer passwords to
resident physicians, so that the residents could cosign their own
reports without supervision. Unsupervised resident physicians create a
serious risk of malpractice, and the VA’s

identified 63 malpractice cases between 1997 and 2002 that were caused
by a failure to supervise residents. There may have been many more.

facilities and practitioners have been found liable for malpractice for
errors ranging from misdiagnosis to surgical and medication errors and
inadequate care. It is more difficult to bring a lawsuit against a VA
hospital under federal law than against an independent hospital, and
the cases are tried before federal judges without a jury. (See
Medical Malpractice
What You Should Know for more information.) In spite of this, several
judgments for over $1 million have been entered in military malpractice
cases in recent years. This indicates that federal judges found the VA
malpractice had been very serious.

Does all of this mean
that VA hospitals are giving a lower standard of care than other
hospitals? The answer seems to be yes. A
of the VA program for cardiac care completed by an independent group in
2003 showed that heart patients treated in VA hospitals are more likely
to die from heart attacks or in the 3 years following an attack than
patients of the same age and physical condition treated in non-VA
facilities. VA hospitals were also found to perform angioplasty or
bypass surgery 50% as often as other hospitals. Those procedures can
often extend a life for several years.

you have been injured due to the negligence of a doctor or other
medical personnel at a VA hospital, you should seek the advice of an
attorney. To find an experienced VA medical malpractice attorney, post
your case to the free Case
Evaluation Form
To learn more about VA medical malpractice claims, see Veterans
Medical Malpractice Claims
: What You Should Know.


Marie Buchanan

Researcher, Pastor-Assistant,