The Department of Veterans Affairs Inspector General's Office said Wednesday that deficiencies at the Louis A. Johnson Veterans Affairs Medical Center that allowed a serial killer to go unchecked for two years provide lessons for all medical centers, not just those belonging to the VA.
The OIG's report on "serious multiple clinical and administrative breakdowns" at the West Virginia hospital "goes well beyond the events at Clarksburg and can be used as lessons that other facilities should be focused on," VA Inspector General Michael Missal said in a call with reporters.
"Our goal here is, when we put out an inspection report, it's really for every medical center director to look at to see whether or not they have the same problem," he said.
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Missal released the results of a three-year investigation into the circumstances at the facility that allowed Reta Mays to inject eight veterans, if not more, with deadly doses of insulin.
Mays was sentenced Tuesday to seven consecutive life sentences for each of seven charges of second-degree murder, with additional years added for charges of assault with intent to murder for an eighth victim.
The VA OIG found that the staff at the medical center failed to properly vet Mays before hiring her, and neglected to follow up on her previous employment or on concerns expressed about her background investigation by the Office of Personnel Management.
The investigation also found that the medical room and medical carts on the ward where Mays worked were not locked and all staff had access to pharmaceuticals. Staff also failed to notice or investigate that doses of insulin were missing.
And providers didn't conduct medical investigations into unexplained hypoglycemic events in patients or a rise in unexpected deaths; they also failed to report the adverse events.
"Our report found serious, pervasive and deep-rooted clinical and administrative deficiencies at the medical center," Missal said. "It was a series of missed opportunities that contributed to the criminal action occurring, not being stopped and allowing it to go on as long as it did."
Missal's office had come under fire for the length of time it took to release its health care report, as well as the timeline for the criminal investigation -- more than three years.
Last August, West Virginia Democrat Sen. Joe Manchin urged the Justice Department and VA to conclude the investigation and release the results as lawsuits by the victims' families mounted and anxiety increased.
The VA secretary at the time, Robert Wilkie, also pressed Missal's office to expedite the investigation.
Missal said that the health care review was put on hold until Mays pleaded guilty in 2020, to "not interfere with the integrity of the ongoing criminal investigation."
But, he said, when important issues were uncovered, such as the unlocked medicine rooms and carts, or the fact that the ward had no cameras, his office notified the VA.
"Our role is to help veterans get the highest quality health care, so when we see something like that -- an exigent or urgent situation which has large implications, we are immediately going to let the VA know," Missal said.
He added that the criminal inquiry was lengthy because investigators began with no witnesses, confession or "real hard evidence." They needed to build a case essentially from scratch, going over thousands of pages of documents that included evidence of who entered and exited the hospital at specific times; exhuming the bodies; and bringing in independent experts.
"It's just a long process. ... Typically in criminal cases, you might get lucky. You might get somebody who gives you information, who was an eyewitness or other things. We had nothing here. Nobody, nobody suspected that she did it," Missal said. "It really was just taking the hard evidence and putting it all together."
Missal said his office routinely inspects VA medical centers and has little reason to believe that the issues seen at the Clarksburg VA are endemic across the department.
Noting the timeworn adage, "If you've seen one VA, you've seen one VA," Missal said "leadership sets a tone" at each VA facility and it is up to medical center directors and supervisors to establish a culture of patient-centered care.
"If that culture isn't promoted by leadership, you will eventually get shortcomings either on an administrative or an operational level," he said.
The VA announced Dec. 24 that it had replaced Dr. Glenn Snider, the medical center's director, and made several other personnel changes to improve patient care, six months after Mays pleaded guilty.
-- Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime
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