As has been reported here, the VA had maintained secret ratings of VA Nursing homes, in which 45 of the 133 facilities received one-star (lowest) evaluations. The secret records were made available to the Boston Globe and USA Today, which have continued to cover the story, in which more than 100 VA nursing homes scored worse than private-sector nursing homes on an average of key quality indicators.

The Boston Globe has recently reported on the specifics of the filings of one of the one-star facilities, the 112-bed Brockton (MA) VA Medical Center nursing home. In spring, federal investigators from the VA’s Office of Medical Inspector, seeking signs of patient neglect, visited that site, whose officials had already been informed that they were under scrutiny.

The investigators filed a condemnatory report, citing “a substantial and specific danger to public health and safety.” Immediately, they found that a nurse and nurse’s aide (since fired) were sound asleep during the evening shift. They confirmed the allegations of a whistle-blower nurse that urinal bedpans were not regularly emptied and that veterans were not checked-on at night or provided with clean water. Sleeping on the job was reported as commonplace. One patient’s oxygen tank had been allowed to become empty. Another fell and lost access to a feeding tube for a matter of hours. The attendants could not be identified because the records had been shredded “in accordance with the local policy”. The whistle-blower resigned, citing “retaliation” by site authorities.

The findings were sent to the President and Congress on October 23 by Special Counsel Henry J. Kerner, who affirmed that patients were “routinely receiving substandard care.” Leaders of the Veterans of Foreign Wars (VFW) and American Legion called on the VA to make public the

agency’s reports on conditions at VA nursing homes, especially those with low ranking like that at Brockton, where two veterans with mental health issues were found to have gone years without receiving treatment.

If you are a VA clinical social worker, have you provided care at a VA nursing home? What are your observations and suggestions for improvement?


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