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VA Facility Where Veteran Killed Himself Has Long Been Flagged for Shortcomings

Inspector general highlighted issues with management, hospital conditions

VA hospital
VA hospital / AP
• August 26, 2016 12:25 pm

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The Department of Veterans Affairs medical center that was the site of a veteran suicide earlier this week has a history of failings and shortcomings.

Peter Kaisen, a 76-year-old veteran, shot himself dead on Sunday in the parking lot of the Northport Veterans Affairs Medical Center on Long Island, N.Y., the New York Times reported. The incident is under FBI investigation because it occurred on federal property. According to sources who spoke anonymously to the Times, the veteran shot and killed himself after being "denied service" related to his mental health at the emergency room department.

The medical facility has previously been flagged for shortcomings in its medical conditions, management, and other areas by the VA’s watchdog, according to a Washington Free Beacon review of public reports by the inspector general.

The Northport facility is the same VA hospital that had to close five operating rooms when contaminants began falling from air ducts belonging to its HVAC system, the Times reported in May. An independent environmental analysis obtained by the Times concluded that black particles in the operating room were connected to the hospital’s old and crumbling building and were "typically associated with galvanized duct corrosion and metal piping/fittings."

An assessment of the medical center issued by the VA inspector general one year ago faulted the hospital for not maintaining "safe ventilation, temperature, and humidity levels in inpatient care areas." Hospital staff also did not designate responsibilities for cleaning some equipment and stored clean and dirty items together in several patient care areas, the inspector general found.

Additionally, the facility did not have a policy for identifying individuals who entered the facility, did not document resources and assets for emergency use, and had an incomplete emergency operations plan, the report revealed.

A similar assessment released by the watchdog in March 2013 faulted the facility for numerous shortcomings in quality management and hospital conditions. There were issues with cleanliness and infection prevention in the hospital’s kinesiotherapy clinic because staffers did not always change linens on exercise equipment between patient uses. Medication in the physical therapy clinic was stored "on an unsecured, dirty table."

"Store clean and dirty items separately," the inspector general advised hospital leaders. "Ensure kinesiotherapy clinic staff consistently change linens and clean equipment between patient use. Replace stained privacy curtains in the kinesiotherapy clinic, and routinely inspect and replace curtains as needed. Secure medications in the physical therapy clinic."

The facility has also been investigated by the inspector general over allegations of poor patient care and other misconduct.

The watchdog investigated the medical center in 2012 in response to allegations that a patient diagnosed with dementia received poor care after falling and cutting his head. The inspector general found that the patient, who was admitted to the hospital’s emergency department and later transferred to the psychiatric unit, "did not receive effective and timely pain management from the facility surgeon or staff on the psychiatric unit after the fall." Facility staffers did not follow VA "clinical disclosure policies and did not adequately respond to the family’s complaints."

The inspector general investigated the medical center’s nuclear medicine service in 2010, finding that "the medical center was operating an unaccredited residency training program in nuclear medicine" and that the chief of the nuclear medicine service "allowed unqualified individuals who were not licensed to practice medicine in the U.S. to work in Nuclear Medicine Service." The investigation resulted in the discontinuation of the training program.

Finally, a 2006 probe by the inspector general found that the director of the medical center at the time allowed a subordinate and others "to lodge in rooms at the medical center that they were not authorized by law to occupy." The rooms were intended to house veterans receiving care at the medical center.

When contacted, a spokesman for the Northport VA did not address inspector general reports disclosing shortcomings at the hospital but expressed sympathy for Kaisen’s family.

"There are no words to adequately convey our heartfelt sympathy to the family, friends and neighbors of the Veteran involved in this  terrible tragedy," Todd Goodman, a spokesman for the Northport VA, told the Free Beacon. "The employees here at Northport feel this loss deeply and extend their thoughts and prayers to all those impacted by this tragedy. We are committed to addressing the needs of all Veterans who are in crisis, and want Veterans and their loved ones to know we stand ready to help whenever possible."

The VA’s network of hospitals has been under scrutiny since the 2014 scandal where scheduling staffers were found to be using secret lists to conceal long patient waits for care. Revelations of the practice, which resulted in the deaths of veterans waiting for VA appointments, prompted the resignation of then-VA Secretary Eric Shinseki and new legislation aimed at boosting accountability at the agency.

Shortcomings have remained, as the VA has been cited for wasteful spending, poor management, and persistent waits for care. An independent assessment released last September found that flaws at the VA’s network of health facilities warranted "system-wide reworking."

"The Northport VA has been repeatedly flagged for inadequate training, misuse of resources, and unsatisfactory conditions at the hospital," Dan Caldwell, vice president of policy and communications at Concerned Veterans for America, told the Free Beacon. "But sadly, the ongoing issues there are unremarkable in the grand scheme of gross mismanagement and dysfunction at VAs across the country. Unfortunately, tragedies like the untimely death of Peter Kaisen are far too common."

According to the Times, an individual who works at the Northport hospital said that Kaisen sought care at the emergency room and was denied service. He then "went to his car and shot himself." A spokesman for the hospital said there was "no indication" Kaisen went to the emergency room before the incident.

"He went there for help with depression," a longtime friend of Kaisen told Fox News. "That was his last hope, and he didn’t get any help."

Scrutiny surrounding the VA’s efforts to prevent veteran suicides has been especially high given data showing that roughly 20 veterans nationwide commit suicide each day. The VA has made suicide reduction a top priority and aims to boost mental health treatment at its facilities.

Still, the agency has been faulted for allowing veterans’ calls to its crisis hotline to go to voicemail, and several VA hospitals have been flagged for insufficiencies in their suicide prevention programs, the Free Beacon reported earlier this year.

Published under: Veterans, Veterans Affairs