As I went to catalog more of the Department of Veterans Affairs (VA) – Office of Inspector General (VA-OIG) reports, Nickelback’s song, “If Everyone Cared,” was playing. I cannot think of a better title to proclaim the need for raising awareness and what is needed to fix the VA. Until everyone is aware and the scab hiding the infection inside the walls of the VA are ripped away to be exposed to the sunlight disinfectant, nothing will change, and taxpayers will continue to pay for the abuse of veterans who deserve so much more.
We begin with an indictment and a reminder. An indictment does not indicate guilt or innocence, and the parties mentioned are presumed innocent until proven guilty in a court of law by a jury of their peers.
“Scott Mitchell Brown, John Henry Swiencki, and David Jeffery Hughes, Jr., were all charged with one count of conspiring to distribute hydrocodone, oxycodone, and amphetamines. Brown was also indicted for stealing prescription medications, possessing stolen mail, and obtaining unauthorized health information from the Kerrville VA Medical Center in Texas.”
I am a big fan of punishing liars and thieves of all stripes and support justice served in this case.
“David Naylor, 59, of Spring Hill, Florida, was sentenced to two years and three months in federal prison, followed by three years of supervised release, for theft of government funds. Naylor made false representations regarding his physical limitations in connection with his application for VA disability compensation.”
While the following perpetrator has been caught and sentenced, she represents but the tip of the iceberg.
“Rita Copeland, 59, of Portsmouth, Virginia, was sentenced today to nine and half years in prison for wire fraud and aggravated identity theft in connection with schemes to defraud veterans. She operated Veteran Services of the Commonwealth, which claimed to provide veterans with caregiving, contracting, and rental assistance services. In total, from at least 2017 through 2020, Copeland’s schemes impacted at least 29 victims and resulted in a combined loss of approximately $430,000.”
Again and again, the following questions are asked and never answered; yet, the questions remain pertinent. Who at the VA had to have known this abuse of veterans was occurring and did nothing to stop the abuse? There are too many checks and balances, too many hands, and too many inspectors for fraud of any magnitude to exist for very long without raising flags needing investigating. Where were the VA employees? Who knew? What did they not do? Are they still Federal Employees?
Another veteran died, needlessly at the hands of VA providers, due to ineptitude, failed management, poor training, and a series of unfortunate events that cascaded. I weep for the family of this veteran and mourn for their loss. I am sorry you have had to experience this tragedy and wish there was something more I could do than simply spread the story of this deleterious behavior and hope for sunshine disinfectant. The patient died from “presumed anoxic brain injury (his brain failed to receive enough oxygen).”
“The VA-OIG found that physicians’ failure to provide adequate benzodiazepine dosing to address the patient’s delirium tremens, review the patient’s abnormal electrocardiogram before haloperidol administration, and transfer the patient earlier likely contributed to the patient’s deterioration and ultimate death. The VA-OIG substantiated that a non-VA paramedic documented that the oxygen flow was not active. Facility leaders and staff reported a lack of knowledge about the failed oxygen delivery. The nursing staff did not complete all required alcohol withdrawal assessments. A physician improperly ordered restraints, nurses failed to obtain full vital signs while the patient was in restraints, and nurses did not receive restraint training as expected. The VA-OIG substantiated that facility leaders and staff did not communicate initiation of emergency detention with the patient’s family; however, notification is not required. Leaders did not conduct an institutional disclosure with the patient’s family timely or in person and did not provide a relevant update.”
Did you catch that last sentence; while the patient was dying, the facility leaders and providers, including the nursing staff, were more concerned with CYA (covering their own acts) than notifying the family they had screwed up, and their family member had died. If the nursing and staff did not have the training, why and how could they use restraints on a patient? This is blatantly illegal!
Let’s cover one more egregious item from this summary of unfortunate events; I visited a doctor who is transitioning out of medicine who made the following comment, “Medicine has changed, practicing medicine has changed, and the practice of medicine is no longer about treating people, but checking boxes, the patient be damned!” The patient was a “walking chemistry experiment, and no single nurse or provider took a minute to stop providing care, assess the patient, and stop administering drugs! Instead, they just kept pumping more drugs in until the patient died and then covered their tracks with designed incompetence to protect their failed inadequacies. This is not “practicing medicine,” you would not treat an animal in this manner; at least not and keep your license!
A death row convict is not allowed to die from anoxic brain death, as it is considered incredibly painful and a cruel and unusual method of death, which is why the gas chamber has been banned as a legal means of causing death for death row inmates. Yet, under a medical team’s care, a patient in a VA hospital is allowed to die in this horrific manner, and nobody is held accountable. Is it any wonder why this article is suitably titled “If Everyone Cared?”
Not many outside of the veterans affected and their families know that the VA has been pushing opioids for decades down the throats of veterans. At the height of the opioid crisis, the VA shut off all opioid drugs and told the veterans to seek help for addictions to pain medications. The VHA did not evaluate the individual patients for need, did not seek alternatives, did not try to reduce dependency over time, simply cut off all opioids, and told the veterans to deal with the problems. Unfortunately, opioids were not the only drug series that the VHA cut off suddenly on veterans without notice, cause, or individual patient consideration, and deficiencies in coordination for the care of patients and drug mandates from VHA has lead to suicides, murders, and other violent problems as addictions cause social problems.
When discussing failures to coordinate care for patients, abuse of patients, and the need for patients to be housed in the proper treatment centers for their needs to receive the right care, the following should boil your blood and comes from Fayetteville VAMC in North Carolina.
“The VA-OIG identified that the psychiatrist used the involuntary commitment process in a manner that was inconsistent with the state’s established parameters and failed to adequately assess and document the patient’s capacity to make informed decisions and determine whether the patient had a healthcare agent. In addition, the patient’s primary care providers and psychiatrist missed an opportunity to coordinate specialty care needs for the patient.”
Essentially, a bureaucrat incarcerated a veteran against their wishes, without a trial, an appeal process, and proper medical care. Now, imagine you are the family of this veteran or a friend, and you see this occur and feel powerless to help, impotent to intercede. Every avenue you approach is blocked because of the authorities, the bureaucrat in charge who wields their power illegally. How do you feel? What do you do? Where do you turn? Is it any wonder why this article is suitably titled “If Everyone Cared?”
America, we need to care about what is happening in our representative government, in our name, with our tax dollars, and to our neighbors, family, and friends. There are no excuses for the abuses witnessed! There are no excuses for medical providers to get away with this outrageous behavior in private hospitals or government-paid-for-care. Let us all heed Nickelback’s song and the intent; let us be the “everyone” who cares!
© 2021 M. Dave Salisbury
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