The week of 27 September 2021 started funkily and has gone downhill rapidly! I reported Monday being refused medical service for not wearing a mask. On Tuesday, I visibly struggled for breath, standing in the VA pulmonologist’s office in front of the pulmonologist who was holding my pulmonology function test results. I am holding a letter showing I cannot wear a mask, wearing a face shield, and being told by the doctor, “I do NOT care, he needs to WEAR A MASK, or I AM NOT SEEING HIM” [emphasis his]. Eventually, the doctor agrees to see me, provided I remain more than 6 feet from him, and he does not have to touch me. The doctor then proceeds to lecture me about getting the vaccine, wearing a mask, and of course, breathing through my breathing difficulties.
As they say on the Home Shopping Network, “But wait, there’s more!” Crazy has only just begun, unfortunately!
A patient with iron-deficiency anemia died at the hands of VA Doctors at the San Juan Puerto Rico VAHCS (2017), and the VA-OIG is just completing and reporting on their death in 2021. The patient who came in for a colonoscopy developed rectal bleeding, which required an anticoagulant, and the patient subsequently died. A tragic set of dominoes was set up and knocked down in this patient’s case, and the VA is entirely at fault for the patient’s death. How badly the patient’s family must feel with this report in hand and knowing they can do absolutely nothing!
100% crazy indeed; but wait, there’s more!
Justice was served cold and raw, and while I was hoping for a harsher sentence by far, I am still hoping his victims can recoup some of their losses and obtain retraining. “Jonathan Dean Davis, the owner of Retail Ready Career Center in Texas, was sentenced for deceiving the VA of $72 million. Beginning in 2014, he offered six-week heating, ventilation, and air conditioning course, promising to prepare veterans for careers in the HVAC industry. However, upon entering the workforce, many of these veterans discovered that the course had failed to teach them many of the basic skills necessary for entry-level technician jobs. Davis was also ordered to pay $65.2 million in restitution and forfeit $72.5 million to the federal government.”
It is very hard to describe what goes into the GI Bill besides money and time in service. It is even tougher to explain how cheated you feel when the benefit is cut by the government, stolen by school administrators, and reduced by petty rules and regulations. To see your benefits stolen through shoddy training and see your hopes and dreams dashed, as well as your benefit, turned into useless paper, the heartbreak is incredible! The punishment for all involved should have been greater, and some federal employees should have shared the blame for failing to do their jobs!
Hold onto your seat, folks; the insanity has not even reached its peak yet; there’s more!
“The VA Office of Inspector General (OIG) inspected the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize the risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions. The VA-OIG substantiated a failure to observe general infection control practices, including in the following areas:
- Leaders failed to minimize the risk of exposure to COVID-19.
- Leaders did not respond adequately to staff exposure.
- Leaders did not have a plan for the transfer and isolation of residents.
- Leaders did not implement recommended infection control measures when performing aerosol-generating procedures and continued to hold group therapies.
The VA-OIG substantiated the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure. The OIG identified actions taken by leaders following the CLC outbreak that lacked input from frontline staff to identify corrective actions and opportunities for improvement.” This is the politically correct way of saying that the community living center leaders are thoroughly incompetent and should not be trusted in their current positions.
Leadership failure in spades, employees, patients, families all placed at risk because of incompetence and politics of the facility leaders, and the VA-OIG does not have the teeth needed to FIRE and REPLACE the leaders who are clearly out of their depth and ability! For months the media and political leaders have been harping and preaching how dangerous COVID as a viral infection is. Yet, the leaders in the Illiana VAHCS seem to be operating to a different set of rules and policies. Will any elected leader be asking why? Insanity runs deep in Illinois!
On the topic of COVID-19, and the failures of VA providers to do their jobs, we find another dead veteran due to what in the private sector would be a classic case of malpractice! Yet, care at the VA is protected from malpractice, and the providers are safe from responsibility and accountability for their failures. While the following is specific to North Carolina, similar examples are found across the United States. Insanity thy name is represented in spades at the VA!
“The VA OIG conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.”
- The VA-OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient.
- The VA-OIG substantiated that dietitians conducted incomplete nutritional assessments.
- The VA-OIG substantiated that the patient’s PACT nurse and dietitians failed to coordinate care by not communicating the family’s request for a face-to-face appointment and the patient’s declining nutritional status to the primary care provider.
- The VA-OIG found that incorrect scheduling resulted in the patient not being seen by a dietitian for a follow-up appointment and a delay in scheduling a non-VA dental appointment.
“The VA-OIG concluded that COVID-19 impacted the care provided by dietitians because of the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical characteristics caused by a declining nutritional status.”
Blaming a viral disease for the failure of people to do their jobs is the height of skullduggery, showing pusillanimous disregard for the patient and a timid weak-kneed, and yellow-bellied timorous approach to medicine. None of you deserve to be in the medical field if you cannot properly take personal protection and see patients who need to be physically seen! Now, let’s call a spade a spade and call out your wimpy, limp-wristed, lily-livered weakling leaders who refuse to act like leaders in a hospital and prefer to act like scared amoebas in a petri dish! There is NO EXCUSE for your paltry excuses, your shady practices, and your hiding in offices and behind the disruptive behavioral committees when your policies and procedures FAIL when YOUR training plans fall apart, and when reality bites hard enough to disrupt hospital operations and your policies are the problem endangering patients!
Crazy… Thy name is abused in the VA, and the leaders are failing to understand sanity! But … wait, there’s more!
There are times when I describe the insanity at the VHA, VBA, National Cemeteries, and the Department of Veterans Affairs (VA) as designed incompetence. The following is the purest example of designed incompetence witnessed to date. Consider with me the following:
Blue Water Navy Outreach requirements were met, but processing and procedures remain lacking and need improvement. The VBA was legislatively mandated to extend veteran benefits to a classification of sailors who operated in blue water conditions off Vietnam or within 12 Nautical Miles of Vietnam. The VBA went forward and established the computers, the records, the systems, etc., to handle these claims. The results, a complete farrago!
“The VA-OIG substantiated that the VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions.”
Did you catch that the VBA intentionally designed a system that failed to perform the task because humans and computers were lenient to deviate? Nobody is held accountable for the continued loss of benefits, treatment, and wasted resources of the government and the veterans involved! Here’s the rub, this is NOT the first time this has happened! The VBA is notorious for failures like this and never held accountable by the elected officials hired to scrutinize the government! Name a military excursion where benefits had to be carved out by legislative order, and you will find foot-dragging, designed incompetence, inconsistencies in decision making, and piss-poor performance at every level of the VBA. Why?
Let’s imagine you hold a job that has a reporting requirement to an authorizing body that can shut you down. You arbitrarily change language in metrics and reporting, do not tell the authority but still expect the authority to license you and your efforts. How likely do you think the governing body will look favorably upon your changes? The VA is legislatively mandated to report to Congress on its capacity in five areas, spinal cord injuries, traumatic brain injuries, blind rehabilitation, prosthetics and sensory aids, and mental health. But, by changing the language, metrics, and methods of talking about injuries, the VA can hide, misreport, underreport, overreport, and play reporting games with the report to Congress and the VA-OIG second look get away with the deception. Never forget, the maskirovka comes with veteran patient abuse!
The VA-OIG has reported continuously to Congress, to deaf ears and plastic lips, the following, “… VA cannot compare its current mental health capacity with its 1996 capacity because of changes in diagnosis and treatment, service provision, and data collection. For example, VA must report on the number of veterans with “serious mental illness,” but VA no longer uses that term. And non-VA care, which veterans increasingly seek, must be excluded from reports on VA’s capacity to provide care. The OIG believes that by modernizing the reporting metrics, Congress would be better positioned to assess VA’s capacity to provide care for today’s disabled veterans.”
Congress continues NOT to push the VA to adopt 1996 language and metrics for reporting, or change the law to update the language and metrics to capture the data more accurately, thus allowing the lies and deceptions to continue. Will anyone in the media EVER ask Congress WHY?
What kills me, the insanity discussed in this summation of VA-OIG reports does not even scrape the iceberg. In my email inbox, I have to select between continued financial failures by leaders, veteran suicide during an inpatient residency, and the continued moral distress of employees by facility leaders. I have twenty more VA-OIG reports sitting awaiting summation because the insanity has blossomed, and the VA-OIG is working hard to clear their reports for the end of the calendar year. Each and every one of these reports deserve analysis, discussion, and mega-doses of sunshine disinfectant. The sheer enormity of the insanity means that timely discussion physically cannot occur. By overloading the system, the perpetrators of veteran abuse can escape sunshine disinfectant, and that is a sore injustice!
Pray for the families of those who have died at the hands of the VA providers and for those currently dying under the hands of VA providers. Congress needs to act, and we, the electorate, must hold their feet to the fire until they are consumed, or they stand and do their jobs! There are no excuses for the insanity contained in these VA-OIG reports!
© 2021 M. Dave Salisbury
All Rights Reserved
The images used herein were obtained in the public domain; this author holds no copyright to the images displayed.