Boston, Massachusetts is renowned for its medical schools and hospitals, which provide some of the best treatment in the world. So, it’s all the more troubling that a few miles away, in a Department of Veterans Affairs (VA) nursing home in Brockton, veterans have routinely received substandard care.
Recently made public, an internal investigation of the facility conducted by the VA found that “a substantial and specific danger to public health and safety exists at Brockton.” This is worrying, yet comes as no surprise for those following the embattled agency.
Whistleblower Triggers Investigation
The VA investigation was launched in response to a whistleblower, a licensed practical nurse, who spoke up when she saw veteran safety in jeopardy at the Brockton facility. After her superiors repeatedly ignored her, she contacted the VA Office of Special Counsel and demanded they look into the abuse and neglect she witnessed.
They did, and as a result, they were able to substantiate the whistleblower’s claim that residents “were routinely receiving substandard care.” The specific behavior described in the report is astounding – inspectors actually walked in on 2 nurses who were sleeping, 1 of whom was behind a locked door wrapped in a blanket.
Neglect of any kind is dangerous in a nursing home, and the sleeping nurses are indicative of a culture of poor-quality care. Residents of the Brockton facility were 3 times as likely to have bedsores than residents of other private nursing homes. Additionally, residents were more likely than those of other VA nursing home residents to deteriorate and feel serious pain.
These findings are especially disturbing because neglect in a nursing home can be fatal. Last year, a mere 40 miles from Brockton at a VA nursing home in Bedford, Massachusetts, a veteran died because the aide responsible for monitoring him was too busy playing video games.
Veterans and Lawmakers Call for Immediate Change
Veterans groups voiced their disgust at what the investigation uncovered, and they were quickly joined by both U.S. Senators from Massachusetts. In a scathing letter to VA Secretary Robert Wilkie, Democratic Senators Elizabeth Warren and Ed Markey expressed their disbelief and disappointment in the Brockton VA facility, and called for immediate action:
[T]his latest report of patient neglect at the Brockton VA is part of a troubling pattern of misconduct at VA facilities in Massachusetts and across the country, and underscores the need for rapid and lasting improvements in quality of care.”
The problem is nationwide, and it is not new. The “troubling pattern of misconduct” cited by Warren and Markey is evidenced by hordes of anecdotal tragedies, but also by the VA’s own data. After all, the congressmen are not alerting the VA Secretary anything he does not already know. They are imploring him to act on information the agency has been suppressing.
VA Hid of Poor-Quality Nursing Homes for Years
In their letter, the senators rail against the culture of secrecy that has kept the poor quality of VA nursing homes hidden. “For too long,” they write, “we have learned of the mistreatment of our veterans – at Bedford and at Brockton – through the media instead of through VA leadership.”
Their statement is a clear call for those with authority to stop sweeping bad behavior under the rug.
Earlier this year, under pressure from the Boston Globe and USA Today, the VA finally released the rankings they assigned to their nursing homes. Like other nursing homes, the VA monitors its facilities. They conduct unannounced inspections and track quality measures. Unlike other nursing homes, however, VA facilities have not traditionally made their data public.
The latest rankings revealed that VA nursing homes are riddled with problems. One third of all VA nursing homes maintain received 1 out of 5 stars in the latest rankings. As it stands, many veterans would have to drive 1 or 2 states away to get better-than-average care from a VA facility. In a typical VA nursing home, residents are more likely to be given an antipsychotic medication, develop serious bed sores, or have a catheter left in their bladder too long.
Why did they keep this critical information hidden? Is agency reputation more important than veteran safety? Why did a nurse have to turn into a whistleblower in order to get basic care to veterans in Brockton?
There are a lot of questions, but only 1 answer: The VA needs serious reform, in its hospitals as well as its nursing homes. Delivering substandard care to veterans is a grave wrong, and there is only so much time left to make it right.