Veterans center reports show serious violations
BY SHANNON MUCHMORE World Staff Writer
Sunday, February 24, 2013
2/24/13 at 7:04 AM
The well-publicized scalding death of a war veteran in Claremore is among multiple violations - including sexual assault allegations - at the state's seven long-term care centers for veterans, according to a Tulsa World review of inspection reports.
The World reviewed the three most recently available annual inspection reports for each of the state's seven veterans centers. Problems and allegations include:
After Minter's death last May, a state legislative panel heard from family members of other veterans who described abuse within the facilities. The panel also heard from veterans center employees who described a culture of intimidation that they said was intended to keep a facility's problems quiet.
- The Ardmore center failed to protect five residents from sexual abuse by an employee in 2010 and kept the employee at work despite a recommendation that he be fired.
- The Claremore center - where 85-year-old veteran Jay Minter was scalded in a whirlpool and later died - was understaffed and had facility problems such as disorganized mealtimes and dangerously crowded hallways.
- At the Norman center, multiple residents developed pressure sores. Relief devices were not provided, and staff could not identify residents at risk.
Oklahoma Department of Veterans Affairs Executive Director John McReynolds said centers constantly monitor situations to ensure that residents are safe.
McReynolds, who was interim director for four months before being named executive director in December, acknowledged that there have been problems in the past.
"I think it's just a lack of attention and a lack of supervision," he said.
The agency still has work to do to make the centers better, but there have been improvements, he said.
"I think we're doing so much better than what the public sees in the papers," he said.
Serious problems revealed
A 2010 report shows that a resident died at the Ardmore Veterans Center after not receiving proper treatment.
The resident had gastrointestinal distress for two days before dying and was not properly treated by a physician, according to the report. The assistant director of nursing told investigators that nurses don't call doctors because they get "chewed out" for doing so and instead "flag" them via computer.
The resident's condition was flagged, but a physician did not acknowledge it until five days after the resident died.
The report says a physician was made aware of the resident's symptoms when he was experiencing them, but there was no evidence of any medical intervention.
The next year, the facility failed to perform timely investigations of alleged abuse, did not properly perform criminal checks on new hires and did not report substantiated abuse to the proper state board.
The report revealed that in past years, two employees had been fired for abuse and one had been fired for exploitation/misappropriation of a resident's money.
A resident said he filled out a complaint about a certified nursing assistant who had been previously reprimanded, but the complaint was torn up and the resident was told it would be handled internally.
In April 2010, that certified nursing assistant is alleged to have sexually assaulted a resident, according to a report. The employee's termination was recommended, but administrators overturned the recommendation and suspended the employee for five days.
In September of the same year, a different resident said the same employee had abused him by inserting fingers into the resident's rectum. Administrators said it was inappropriate but did not constitute abuse.
Police arrested the employee and accused him of rape by instrumentation. Prosecutors in Ardmore declined to pursue charges because the witness had died, Oklahoma Department of Veterans Affairs spokesman Shane Faulkner said.
The reports reveal that the same employee then was alleged to have abused three more residents. He would block doors to rooms to be alone with residents, particularly those who couldn't talk, according to the reports.
'Lack of supervision'
War Veterans Commission Chairman Rich Putnam said many problems have been addressed through reorganization.
The War Veterans Commission oversees the Oklahoma Department of Veterans Affairs, and both have had significant changes.
"The situation that we found was a lack of oversight and a lack of supervision," Putnam said of the state Department of Veterans Affairs, which oversees veterans centers.
Gov. Mary Fallin replaced eight of the nine War Veterans Commission members in May. Since then, five of the veterans center administrators have changed.
In addition, the executive director of the Oklahoma Department of Veterans Affairs changed in 2012. McReynolds succeeded Martha Spears, who retired in July, citing her husband's health.
A deputy director has been hired, and the position of claims and benefits director was created. Jobs that were vacant are being filled, Putnam said.
The commission doesn't like to see any deficiencies at the veterans centers, he said.
"I don't know that we will ever reach perfect, but that, of course, is our goal," he said. "We want to try to get there."
Sen. Frank Simpson, R-Ardmore, who led the legislative review, said he wasn't surprised by the deficiencies in the past.
The vast majority of veterans are getting good care, but there is no excuse for even one veteran being abused or neglected, he said. Simpson is not convinced that the administrative changes made so far will fix the problem.
"I think they're on the right path, but I'm not happy with the current administration," he said.
Simpson filed a bill in the current legislative session that would put veterans centers back under the jurisdiction of the Oklahoma State Department of Health for inspections, as they were until 2003. Simpson's bill would mandate one unannounced inspection annually by the Department of Health.
Currently, the U.S. Department of Veterans Affairs conducts inspections, and they focus more on programs and procedures than on patient care, Simpson said. The state Health Department inspections would focus on things such as treatment.
Advocates of Simpson's bill, which passed the Senate appropriations committee last week, say it would safeguard residents by giving them a place to make complaints and would ensure independent review of the centers.
McReynolds said he thought such inspections would be redundant, but he said the agency will follow whatever rules the Legislature sets.
Simpson has another bill pending that would make the governor responsible for hiring the executive director of the Oklahoma Department of Veterans Affairs, subject to confirmation by the Senate. The War Veterans Commission, which currently appoints the director, voted Friday to oppose that bill.
Oklahoma veterans centers reports
The Tulsa World reviewed the three most recently available annual inspection reports for each of the state's seven veterans centers. Here is some of what those reports revealed:
A report showed that a resident didn't receive proper treatment and died.
The center failed to protect five residents from sexual abuse by an employee in 2010 and kept the employee at work despite a recommendation that he be fired.
Employees had difficulty properly thickening liquids to make sure residents didn't choke. Nurses were unsure how much thickener to use and sometimes used too little or too much.
No interventions were put in place for at least two residents after numerous falls, including some that resulted in injury.
Inspectors also documented holes in walls, chipped paint, missing tiles and missing particle board pieces that created a hazard for residents.
One resident had a pressure sore that continued to deteriorate and became infected even after staff documented its existence.
A report from 2011 found that an area for patients deemed "heavy care" was understaffed and that an employee said the facility needed more and better nurses. The hallways were dangerously crowded with lifts and other equipment.
During mealtimes, residents sitting at the same table were served at different times, and some residents had to wait up to 30 minutes before staff members were able to help them eat.
A report noted that sanitary requirements were not met, as staff wore the same gloves to give out food as they did to touch trash and residents' wheelchairs. They did not wipe down tables between serving residents.
The facility also failed to provide necessary care and services to prevent aspiration to a resident with a feeding tube and did not have adequate supervision or provide assistive devices such as padded pants to prevent accidents and injuries.
It also failed to monitor blood pressure for residents receiving hypertension medication and did not notify the doctor when blood pressure went beyond specified parameters.
A 2009 report found that staff were cutting and pasting health-care notes and were administering drugs not recommended for the elderly. One resident received ear drops in his eyes. Several lifts and tubs were dirty.
In a 2010 report, investigators found seat belts and thigh strap restraints being used without assessments, while another resident was not wearing hip protectors as ordered by his doctor.
Multiple residents developed pressure sores. Relief devices were not provided, and staff could not identify residents at risk. One resident was not given nonskid socks despite having fallen seven times.
The environment was not free of accident hazards, and veterans had complained multiple times about a deteriorating lift that had not been checked for six months, even though it was supposed to be checked twice a week. Employees said they didn't have the staff to perform the checks that often.
The facility also did not ensure that employees used proper infection-control protocols. One employee wore the same gloves to shave a resident as he had used to provide incontinence care to the resident.
In 2010, a resident was not properly assessed for his risk of leaving without notifying staff. He was found in a ditch and returned to the facility, but inspectors could find no evidence that the incident had been reviewed.
The need to use restraints was not properly documented, and the facility did not offer a dignified dining experience. It also did not have a trained activities director and did not address the need to monitor sex offenders residing at the center.
Shannon Muchmore 918-581-8378
John McReynolds, executive director of the Oklahoma Department of Veterans Affairs, speaks during a meeting of the Oklahoma War Veterans Commission in the auditorium of the VA in Claremore on Friday. MICHAEL WYKE / Tulsa World