V.A. Hospital in Decatur Promises Changes, After Audit Claims Mismanagement in 3 Deaths

Credit U.S. House of Representatives

The Atlanta Veterans Administration Medical Center near Decatur is not disputing a Federal audit, which linked three patient deaths to mismanagement in the Center’s mental health programs. Denis O'Hayer's Report

  According to the audit, two of the patients committed suicide; the third died of a drug overdose.  The deaths occurred in the past two years.   The chairman of the U.S. House Veterans’ Affairs Committee, Florida Republican Jeff Miller, told WABE he plans to visit the VA hospital sometime in the near future…and may call a formal hearing.

“The thing that’s most egregious about what occurred at the Atlanta VA Medical Center is that the director received bonuses, after there were deaths that occurred like this at their facility,”  Miller said.

In two separate reports, the VA’s Inspector General looked at the hospital’s in-patient and out-patient mental health services.  The outpatient mental health program, according to the report, is provided by a contractor, the DeKalb Community Services Board.

The findings included failure to adequately monitor patients; inadequate staffing and searches for contraband; and what one report called “patients falling through the cracks.”

Among the recommendations:  national policies for contraband, visitation and drug screens; better program oversight; and functional life support equipment in mental health units.

The reports also recommended that the VA’s Undersecretary for Health “rectify the deficiencies…with respect to the provision of quality mental health care and contract management.”  Another recommendation called for the Facility Director to “evaluate the care of patients discussed in this report with Regional Counsel for possible disclosure(s) to the appropriate surviving family member(s) of the patients.” 

In a statement to WABE, hospital chief of staff Dr. David Bower said, “The Department of Veterans Affairs (VA) concurs with all of the Office of Inspector General Office of Healthcare Inspections recommendations and is committed to providing the best care possible for our Nation’s Veterans.  Bower continued, “VA will monitor the quality mental health care and contract management, and will ensure that Veterans receive the highest quality medical care from either the VA or its partners.”

Miller told WABE he also wants punishment for those involved in the mismanagement.

“Unfortunately, what we see in the culture at the VA is that, when people don’t do their jobs correctly, they just get moved somewhere else,” Miller said.  ”Folks need to understand there are consequences to their actions.”

When asked if he could cite specific examples where Atlanta VA employees were shifted instead of disciplined for poor performance, Miller said, “I’m not ready to say that at this point.  I’m still reviewing the Inspector General’s report.”

Miller said he has not yet set a date for his visit to the Atlanta VA Medical Center.