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Monday, September 9, 2013

Special Counsel Reports Concerns about Mississippi Veterans Hospital to the White House and Congress

In a letter today to the President and Congress, Special Counsel Carolyn Lerner raised concerns
aboutt he G.V. (Sonny) Montgomery VA Medical Center (VAMC) in Jackson, Mississippi. The letter summarizes whistleblower disclosures brought by five VAMC employees and physicians. The whistleblowersallegations 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 include:

• First, 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.

• Second, 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.

• Third, in 2011, a whistleblower disclosed thatJackson 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.

• Fourth, 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 MedicareHome Health Certifications. On February 28, 2013,OSC referred this case to
the VA Secretary for an investigation, which is pending.

• Fifth, 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,” Lerner said. “We urge the VA to carefully investigate and take corrective action.”