The Department of Veterans Affairs inspector general systemically failed to review a Wisconsin VA medical center’s lax authorization of prescription drugs, according to a U.S. Senate report released Tuesday.
The 350-page Senate Homeland Security and Governmental Affairs Committee report concluded that the watchdog failed to "identify and prevent the tragedies" at the Tomah VA Medical Center nicknamed "Candy Land," USA Today reported.
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The inspector general’s office discounted key evidence, narrowed its inquiry, and failed to publicly release the findings of a critical two-year investigation that unveiled providers at the Tomah facility were overprescribing narcotics, according to the Senate report.
The watchdog’s probe, which wrapped up in 2014, found that the facility’s chief of staff at the time, David Houlihan, and nurse practitioner Deborah Frasher were prescribing narcotics at disturbing levels but nevertheless failed to substantiate wrongdoing.
The inspector general’s office shared its findings with local VA officials instead of releasing the report to the public. USA Today noted that VA officials would have been compelled to remedy the charges were the report published publicly.
John Daigh, a lead investigator for health care inspections, decided to keep the report secret because it failed to find the providers had committed any wrong doing, despite "potentially serious concerns" raised by the probe. He told a Senate panel that he decided to withhold the report because he could not publish "salacious allegations."
Five months after the probe’s conclusion in August 2015, former U.S. Marine Jason Simcakoski died at the Tomah facility of "mixed-drug toxicity." His death came days after Houlihan prescribed Simcakoski an opiate on top of the 14 drugs he was already taking.
The VA launched a separate investigation following the 35-year-old’s death, which found Houlihan and Frasher had committed misconduct. Both were later expelled from Tomah.
"In just three months, the VA investigated and substantiated a majority of the allegations that the VA OIG could not substantiate after several years," the Senate committee’s report concluded.
Sen. Ron Johnson (R, Wis.), who chairs the committee, said the report revealed "systemic" failures that showed the VA inspector general’s office needs to "clean house."