Carolyn Lerner, the head of the agency charged with protecting federal employees who act as whistleblowers, asserted that the Department of Veterans Affairs has consistently ignored warnings about the seriousness of systemic problems that put veterans' health and safety at risk.
Lerner offered her conclusions in a letter to President Obama Monday.
"I remain concerned about the Department's willingness to acknowledge and address the impact these problems may have on the health and safety of veterans. The VA, and particularly the VA's Office of the Medical Inspector (OMI), has consistently used a "harmless error" defense, where the Department acknowledges problems but claims patient care is unaffected. This approach has prevented the VA from acknowledging the severity of systemic problems and from taking the necessary steps to provide quality care to veterans. As a result, veterans' health and safety has been unnecessarily put at risk," Lerner wrote.
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She cited 10 different cases where whistleblower claims were confirmed but the VA denied they affected patient care. An employee at a Fort Collins, Colo., facility, for example, reported conditions that led the OMI to confirm a shortage of providers, a practice of trying to mask cancelled appointments, alterations of wait times, and punitive measures for schedulers who listed appointments more than 14 days away from the veterans' "desired date." The OSC is also investigating two schedulers at the facility who were reassigned to Wyoming after refusing to comply with instructions to hide true wait times.
Ultimately, the OMI concluded it could not confirm the failure to properly train staff resulted in a danger to public health and safety.
Lerner also cited problems with inadequate psychiatric care at a long-term mental health facility in Brockton, Mass., inaccurate patient information being submitted in Montgomery Ala., and drinking water at a Grand Junction, Colo., facility that had elevated levels of Legionella bacteria, among other cases. In each case, OMI confirmed whistleblower allegations but determined there was no threat to patient health or public safety.
"These cases are part of a troubling pattern of deficient patient care at VA facilities nationwide," Lerner wrote in the letter.
Her agency has more than 50 pending cases, including 29 that have been referred to the VA. Lerner writes that VA cases represent more than a quarter of all cases referred by her agency for further investigation across the entire government.
The entire VA system is under investigation in response to increasing allegations of misconduct at facilities across the country.
Lerner recommended that the agency delegate a high-level official to look into the conclusions reached in the various whistleblower cases to determine if there are broader or system problems that require attention.