ABCNEWS.com – April 9, 2004
Fourteen years ago, an ABCNEWS hidden-camera investigation ignited a
firestorm about conditions and competence inside Veterans
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.
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
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
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
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."
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
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
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.
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
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
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
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."