According to a recently released report from the Veterans Affairs Office of Inspector General, a health care inspection done over a nine-month period ending in August 2015 for the VA Greater Los Angeles Healthcare System yielded shocking results: 43 percent of veterans who died during the nine-month period were still waiting on care due to improper delays.
The OIG report found that 117 out of the 225 patients who died with 158 open or pending consults died while experiencing a delay after a requested consultation. According to the report, these delays occurred because providers and office staff did not consistently follow proper rules or procedures.
Though the report could not prove the patients died as a direct result of the improper delays in care, it did find two patients with what the report called "intermediate impact" and "minor impact."
Providers entered incorrect urgency and/or incorrect inpatient/outpatient settings in 14 percent of reviewed cases. They entered incorrect consult service settings for 9 percent of reviewed consults, and incorrect consult urgency in an additional 5 percent of cases.
The report called the delays "deficient," noting that the staff did not act in a timely manner on clinical consult requests, close completed consults, or monitor the wait list for home health care services. Had the facility staff done these things, a more accurate report could be generated, the Office of Inspector General purported.
The OIG report, explicitly stating the findings were not an allegation but rather a recommendation, suggested that facility staff start taking action on consults within one week or sooner and keep better track of consults that need to be closed as well as more closely monitoring the home health services list.
The news comes after the House of Representatives passed legislation in March allowing VA officials to terminate, demote, or suspend employees based on performance or misconduct. Sen. Marco Rubio (R-Fla.) introduced the same bill in the Senate, titled the "VA Accountability First Act."
Rubio's website says that a recent study determined that removing a federal government employee takes about six months to a year, on average.
"The VA Accountability First Act will give the VA secretary increased flexibility to remove, demote, or suspend VA employees who fail to take care of our veterans," Rubio said. "I am pleased President [Donald] Trump has made this issue a priority, and I look forward to working with [VA] Secretary [David] Shulkin to hold VA employees at all levels accountable for their performance and ensure our veterans are no longer ignored or mistreated."