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Veterans Die in VA Facilities After Disease Outbreak; 'Rampant Mismanagement and Incompetence' Cited

"How can we stand by and not hold accountable those who neglected our veterans..."

  • An outbreak of Legionnaires' disease in 2011-2012 within Pittsburgh's health care system for veterans has killed six and sickened 16. 
  • Lawmakers began requesting documents related to the outbreak in January and have called out the VA for a "lack of responsiveness."
  • One family is suing the VA for negligence and others are looking for answers as to why the water system wasn't being maintained in a way to prevent such an outbreak. 
  • In the midst of the scandal involving the bacterial outbreak, management was given a positive review in evaluations. 
  • "These revelations paint a troubling picture of rampant mismanagement and incompetence among some officials within the VA Pittsburgh Healthcare system." -- Chairman of the House Committee on Veterans Affairs Jeff Miller (R-Fla.)

Legionnaires disease The front of a Veterans Affairs hospital in Pittsburgh is seen on Wednesday, Feb. 6, 2013. Faulty maintenance and poor management at two local Veterans Administration hospitals may have contributed to the deaths of five patients from a strain of Legionnaires' disease, according to testimony at a congressional hearing on Tuesday. (AP/Keith Srakocic)

A veterans hospital in Pittsburgh has been under scrutiny for more than half the year in a case of disease, cover up and what some are calling mismanagement. Now, a family has had enough and is suing for wrongful death, negligence and more.

It all stems from a report of a bacterial outbreak in 2011 and 2012 at the Pittsburgh VA, which the Pittsburgh Post-Gazette most recently reported has killed six and sickened 16 to date.

The Post-Gazette and the Pittsburgh Tribune-Review have produced extensive reporting on the issue since it was called out by the House Committee on Veterans Affairs in January 2013. The committee sent a letter in April citing a "lack of responsiveness" by the VA to provide all documents and emails since 2007 discussing the presence of legionella bacteria within the VA's Pittsburgh health facilities.

First, here's a bit of background on the Legionnaires' disease outbreak that started to concern many about the care veterans were receiving at the time. According to an Inspector General report reviewing Legionnaires’ disease in the VA Pittsburgh Healthcare System at the request of lawmakers, once veterans began testing positive for the bacterial disease, the CDC was able to identify nearly two dozen cases of it between 2011 and 2012, finding that VAPHS had "widespread colonization of Legionella" in its drinking water system.

Legionella is bacteria that can be inhaled through mist from water, which can lead to a type of pneumonia called Legionnaires' disease.

Legionella Colonies of Legionella seen under UV light. (Image source: Centers for Disease Control via Wikimedia)

According to the IG report, although VAPHS instituted additional measures to act against the Legionella outbreak, there were several other items that allowed unsafe conditions to persist:

[...] we found that while employing copper-silver ionization systems during 2011-12, VAPHS allowed ion levels inadequate for Legionella control to persist. There was a lack of documentation of system monitoring for substantial periods of time and inconsistent communication and coordination between the Infection Prevention Team and Facility Management Service staff.

We also found that VAPHS did not conduct routine flushing of hot water faucets and showers, especially in areas that are infrequently used, as recommended by the copper-silver ionization system manufacturer. We found that VAPHS conducted environmental surveillance in accordance with Veterans Health Administration (VHA) Directive 2008-010. However, VAPHS responded to positive cultures by flushing distal outlets with hot water at normal operating temperatures, a corrective action not consistent with VHA or Centers for Disease Control and Prevention guidance. In addition, VAPHS did not test all healthcare-associated pneumonia patients for Legionella as specified by VHA guidance for transplant centers with a history of healthcare-associated LD.

The Tribune-Review reported that its own investigation found that the CDC had not asked for the hospital's test results for Legionella, which would have helped it review where the outbreak could have been in the water system.

Fast forward from this April report to June when local news reported more cases being added, new deaths being reported and congressmen continuing to say the VA was ignoring their requests for documents about the outbreak.

In fact, lawmakers were so frustrated with the Veterans Affairs Department's failure to comply with nearly 100 requests for information, that it said in July it would use its website to highlight the inquiries that it says the VA has failed to answer. The panel said its "Trials in Transparency" page will keep a running record of outstanding requests for information.

In the case of the Pittsburgh Legionnaires outbreak, committee chairman Jeff Miller (R-Fla.) told the Tribune-Review that "these revelations paint a troubling picture of rampant mismanagement and incompetence among some officials within the VA Pittsburgh Healthcare system."

"Unfortunately, incompetence and mismanagement — coupled with an extreme reluctance to come clean about the facts — have defined the department's response to the tragic Legionnaires' disease outbreak in Pittsburgh," Miller continued.

Earlier this month the family of WWII Navy veteran William Nicklas, who died at 87-years-old as a result of the disease, launched a lawsuit for $8 million in damages against the U.S. Department of Veterans' Affairs.

"When you're talking about five, and maybe six deaths now, we can't let it go away," the man's son, Bob Nicklas, said according to the Post-Gazette. "We're going to keep pushing and pushing."

The family member of another disease victim victim was reported by the Post-Gazette last month to be looking for answers into his brother's death as well.

"All I know is, when he went in to the VA for some psoriasis, he was OK," Dave Jenkins said of his brother, Greg, whose death at 54 years old was not directly attributed to Legionnaires. "But after, he was never right; he never came back to what he was."

The Post-Gazette stated that, like the family of others who had contracted the disease, Jenkins is pushing for the problems at the VA to be fixed.

"I think everything happens for a reason, and maybe the reason here is that they'll solve the problem and no other veterans will get this disease in the future. And I think I owe it to my brother, too, to find out what happened," he told the Post-Gazette.

While all this news continued to emerge and develop the Tribune-Review pointed out in June that the VAPHS received strong ratings in an evaluation from the VA's regional director Michael Moreland:

CEO Terry Gerigk Wolf gave herself high praise for her performance over nearly two pages of the 11-page annual evaluation for the period Oct. 1, 2011, to Sept. 30, 2012, which the Trib obtained. Wolf said she exceeded expectations in all her duties, oversaw consolidation of three hospital campuses into two with the closing of the Highland Drive facility, strengthened ties with veterans and built workplace respect, among other accomplishments. Moreland gave her the top rating in five critical areas when signing off on the evaluation.

“I don't know what's more disturbing: that five veterans are dead from a Legionnaires' disease outbreak VA Pittsburgh Healthcare officials were too incompetent to stop, or the fact that some of those same executives feel their dreadful mismanagement of the outbreak doesn't bear mentioning in their performance reviews,” said Rep. Miller, told the Tribune-Review.

And he's not the only one spouting off about this evaluation either.

"The same bureaucrats who were paid handsomely for negligence and incompetence also refuse to answer reporters' questions about whether they've removed the deadly Legionella bacteria from hospitals that were built to heal, protect and serve those who served us,"Salena Zito wrote in a column for the Tribune-Review about the issue, stating that it seems people are "too tired to care" about the VA "scandal."

"How can we stand by and not hold accountable those who neglected our veterans, whose love of God and country inspired them to serve and preserve our country's people and our fundamental liberties?" Zito continued later in her piece.

The VA system in Pittsburgh is not the only one to battle with the bacterial outbreak either. Just this month, health officials said Ohio is seeing its largest outbreak of Legionnaires' disease, which has killed five people and sickened 39 others at a retirement community since July.

The state Health Department says the outbreak at Wesley Ridge Retirement Community in Reynoldsburg in central Ohio has been linked to bacteria in an air conditioning cooling tower and several water sources.

The retirement community has taken steps to clean the water by hyper-chlorinating and superheating it. The center is also installing filters on shower heads and advising residents not to drink the water until testing is completed.

The Associated Press contributed to this report. 

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