Connolly Statement on DC VA Medical Center IG Report

Press Release

Congressman Gerry Connolly (D-VA), Chairman of the House Subcommittee on Government Operations, released the following statement on the Veterans Administration Office of Inspector General report on the Washington, D.C. VA Medical Center.

"This is a very troubling report that describes a culture of indifference and callousness to patients experiencing mental health issues. Veterans must be treated with care and sensitivity. For a physician to actually say,"[the patient] can go shoot [themself]. I do not care," is disgusting and this individual should have been terminated immediately. I appreciate the constructive recommendations offered in this report, and expect the Director to immediately implement these safeguards and continue to keep all stakeholders apprised of progress being made."

The OIG report made the following recommendations:

1. The Washington DC VA Medical Center Director ensures that Emergency Department staff adhere to Veterans Health Administration suicide prevention policies and monitors compliance.

2. The Washington DC VA Medical Center Director ensures that patients are adequately assessed for withdrawal risk and provided with appropriate disposition for management of withdrawal.

3. The Washington DC VA Medical Center Director ensures staff education of the Veterans Health Administration and Washington DC VA Medical Center policies related to employee misconduct and patient abuse, and monitors compliance.

4. The VA Capitol Health Care Network Director reviews Washington DC VA Medical Center leadership and supervisory response to allegations of employee misconduct and patient abuse to determine if administrative action is warranted and takes action as appropriate.

5. The Washington DC VA Medical Center Director determines leaders' authority and duty to report physician 2's behavior to the State Licensing Board and National Practitioner Data Bank and takes action as indicated.

6. The Washington DC VA Medical Center Director establishes comprehensive quality monitoring of the required hand-off communication processes, including interdisciplinary participation and monitors compliance.

7. The Washington DC VA Medical Center Director makes certain that Emergency Department staff reconcile diagnostic and care plan information that may vary across providers and shifts when determining a patient's final disposition.

8. The Washington DC VA Medical Center Director ensures that Emergency Department staff include the patient and family members, in the development of a care plan as appropriate, and monitor compliance.

9. The Washington DC VA Medical Center Director ensures that facility staff complete Suicide Behavior and Overdose reports as required.

10. The Washington DC VA Medical Center Director establishes quality monitoring of consult scheduling procedures and monitors compliance.

11. The Washington DC VA Medical Center Director expedites Emergency Department renovations to ensure a safe and secure area for evaluation of mental health patients.

In May, Chairman Connolly sent a letter to Director Heimall requesting information following a NBC 4 report that a psychiatric patient escaped from a locked area at the facility. In June 2019, Connolly held a hearing on the DC VA Medical Center and grilled Director Heimall on a "culture of complacency" within DC VAMC leadership and how this culture creates institutional barriers to addressing longstanding problems at the DC VAMC.

In April 2017, the VA IG released a rare and concerning interim report detailing critical vacancies and unsanitary conditions at the medical center. In March 2018, the IG released a troubling final report that found systemic and programmatic failures at the medical center.

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