Audit critical of care at VA center

ATLANTA — A new federal audit finds that three deaths occurred in the past two years under the watch of the Atlanta VA Medical Center after authorities say it lost track of mental health patients referred to a contractor and failed to keep a close watch on those under its own care.

The audit by the Department of Veterans Affairs’ inspector general began last year and found that many of the 4,000 patients the veterans’ hospital referred to the DeKalb Community Service Board “fell through the cracks.”

The Atlanta Journal- Constitution reported one patient died of an apparent drug overdose after waiting nearly a year to be referred to a psychiatrist. Another was told to take public transportation to an emergency department because the Health Care for Homeless Veterans psychiatrist was unavailable. He didn’t go and committed suicide the next day. Another suicidal patient who was supposed to be closely monitored by staff in the hospital’s mental health ward died of a drug overdose after staff members lost track of him for two hours.

Atlanta VA officials did not dispute any of the audit’s findings and say they are implementing its recommendations, from new policies on contraband and drug screenings to a new patient tracking system at the hospital.

“We want to express our heartfelt condolences to the families and friends of the three veterans cited in the reports who died,” Dr. David Bower, the hospital’s chief of staff, said in a statement. “All suicides are tragic events and VA, including this VA, has placed a huge emphasis on suicide prevention. One suicide is one too many. Providing the best health care possible to our nation’s heroes is our goal and we are committed to it.”

Michael Zacchea, a Veterans for Common Sense board member, wondered why the facility was just now starting to systematically track its patients.

“It’s inexcusable,” he said. “I don’t think it’s an indication that they are finally getting it. I think it’s the opposite.”

Atlanta’s VA is one of the most overburdened systems in America, according to Thomas Bandzul, legislative counsel for Veterans and Military Families for Progress. It has eight outpatient centers in metro Atlanta serving 86,000 patients.

The wait list for mental health treatment grew from 53 to 397 patients between 2011 and 2012, and there were 66 vacant staff positions according to the audit. Officials found that a lack of space and low wages for psychiatrists were linked to the vacancies.