Nearly two years after the Defense Department Inspector General's Office asked for information about the death of a resident patient of the Armed Forces Retirement Home in Washington, DC, it is still waiting for answers.
"There were questions raised about the cause of the resident's death and AFRH had begun a 'root cause analysis' investigation," the IG said in a nearly 380-page report released in July. Although the facility's chief operating officer said he would provide the IG with a copy of the report, the home's attorney has refused to provide one, claiming protection from disclosure on legal grounds, according to the IG.
The IG learned of the death in January 2013, after it had completed visits to the Washington and Gulfport, Mississippi, facilities as part of a regularly scheduled inspection. In March, after hearing whistleblower allegations that patients were being put at risk of neglect and injury because of inadequate nursing and medical staff, the IG briefed the Pentagon on its concerns and recommended a team of medical professionals review the medical and nursing operations at the Washington facility.
The IG ultimately made 131 recommendations based on the findings, of which all but seven have been resolved, a spokesman for the Armed Forces Retirement Home told Military.com. The home would not say which issues remain outstanding.
"DoD IG considers 47 of the total 131 recommendations to beclosed. The remaining 84 recommendations, which are open, will be considered closed only after the recommendation recipients have submitted their plans of action to DoD IG for review and have been deemed by the DoD IG to be fully responsive to the recommendations," said Bridget Serchak, an IG spokeswoman.
Notwithstanding operational problems revealed by the inspection, IG officials also found that "most residents of the retirement home were pleased to be living there, particularly the residents of the Independent Living units.
"The quality of life for the Independent Living residents, with numerous recreational activities planned by the Resident Recreational Services office, was quite high," the report states.
Among the operational issues raised in the nearly 380-page report is that the homes were continuing to operate without required accreditation three years after the IG first noted this as a problem and ordered it to be fixed.
The IG found more problems with the Washington facility than Gulfport, which was rebuilt after being all but destroyed by Hurricane Katrina in 2005. Among the issues raised by the IG are the Washington home's incomplete documentation of medical records, medication and nursing notes; promoting people in-house rather than going outside for more qualified employees; and failing to properly handle legal documents and possessions of deceased veterans and retirees.
It also took issue with the home using short-acting opioids rather than more appropriate long-acting opioids to manage pain resident patients' pain, and documenting whether patients using the anticoagulant drug Coumadin were counseled about drug interactions.
The IG looked at 13 different areas of retirement home operations and management, including its medical operations.
The IG also found there was no routine contact between the home's chief operating officer and Defense Department officials responsible for oversight of the facilities. These include the office of under secretary of Defense for Personnel and Readiness and the deputy director of the Defense Health Agency, who serves as the senior medical adviser to the retirement homes.
The IG also found deficiencies with the home's credentialing and privileging processes, including ill-defined qualification requirements, poor training for credentialing personnel, lack of data tracking necessary for re-privileging providers to the home and granting privileges for services that were outside the scope of the home.
The report also notes the many of the home's numerous standard operating procedures, or SOPs, were contradictory, difficult to understand, used references that were not relevant to the subject, or were "markedly out of date."
Both the retirement home headquarters office and the Washington facility "lacked sufficient/competent physician leadership," the IG found.
"Personnel practices at the AFRH tended to promote from within rather than open the positions to outside physicians who may be more qualified," the IG said.
In one case, the IG found that a position description was altered "to allow selection of an internal candidate who did not meet the original qualification requirements. These and other issues contributed significantly to the questionable quality of medical operations, particularly at the AFRH-W facility."
At the agency level and at both facilities, according to the IG, there was not full compliance with directives on medical qualification determination and the reasonable accommodation.
"As a result, some of the nursing staff were incapable of performing the duties that required certain physical and medical fitness," the report said.
At the agency level and at the Washington home there was a lack of adequately trained quality management and performance improvement personnel, the IG said.
At the two homes performance improvement metrics were meaningless – imposed on the facilities from agency level, according to the report. Also, peer reviews were not routine and data needed for re-privileging was not tracked.
The DoD IG also said it was concerned that the inspector general of the AFRH also was designated by the chief operating officer to be its public affairs officer.
This creates a conflict of interest should an investigation pertain to the public affairs office and also hits the credibility of the homes' inspector general office because it falls short of the quality standards IG audits and investigations.
The Washington home also put its elderly veterans at risk by failing to perform adequate testing and monitoring of its "Home Free" patient tracking system. The IG found an unsecured area of the Washington home where monitored residents would have been able to wander off without the knowledge of home staff.
At the Gulfport facility, the resident monitoring system experienced at least 39 outages from early June to mid-September, 2012 – a high enough number over that period that the IG suggested the system may be unreliable.
The IG also found at the Washington facility a security weakness that made unauthorized access to the home possible.
While AFRH security routinely screened people coming onto the grounds– whether arriving by car, bicycle or on foot – to ensure they were employees or legitimate visitors, the Veterans Affairs Department police responsible for the Scale Gate entrance did not, according to the IG. At times they did not even have police at the gate, IG inspectors were told.
The AFRH security chief told inspectors his efforts to get the VA police to follow the same procedures that AFRH guards used proved fruitless because there was no enforceable written agreement requiring them to do so.
By the time the IG publicly released its report in July, an agreement was in effect to further secure the Scale Gate, according to the report.
The IG also found the homes were not properly handling any last wills and testaments, or other personal effects belonging to a deceased veteran. While the law requires that wills be turned over to the court of record, officials at both homes were just as likely to give them, whether originals or copies, to a family member or executor.
When it came to handling personal effects left behind, administrators at the Washington home were not verifying and documenting the identities of the representative handling the resident's affairs or ensuring that the property was delivered to the rightful owner, heirs, executor, legal representative or next of kin.
For veterans who died while in health care – as opposed to those in independent or assisted-living quarters – social workers were likely to take personal possessions left behind and distribute them to other veterans, without first getting the consent of the deceased's family or executor.
"During an interview, a staff member stated that there was a '[culture of] no concern or accountability' when it came to the disposition of resident effects," the IG said in its report.
At the Gulfport home, the IG said officials and workers responsible for handling the effects of deceased veterans said they were following the required procedures but "did not provide sufficient evidence" to back up their claims.
"Ombudsmen at both facilities were not fulfilling their duties ... to supervise and review all actions conducted by personnel involved in the disposition of a decedent's personal effects and the administration of their estate," the IG said. "Moreover, neither facility's Chief of Security was creating log records that accounted for who went in and out of locked rooms containing decedents' personal effects after they were secured."
As of July, AFRH was reworking its standard operating procedures to ensure the proper and legal handling of deceased veterans wills and property, according to the IG.
The IG claims a number of senior personnel at the AFRH Agency and the Washington facility "were insufficiently competent to run the medical operations and to develop and implement meaning [performance improvement] programs."
The IG team also found during its August 2012 inspection that the two supervisory nursing positions at the Washington facility were vacant.
The IG report points the finger at management not opening the vacancy announcements to outside candidates, and said that twice in the past management promoted people into jobs without ever posting the vacancies. In some instances internal job postings were made though only one person held the qualifications, the IG wrote.
Salary offered by management is also a factor. The IG said the agency appears to routinely offer the lowest salary on the GS pay scale, a move that is likely to keep better qualified candidates from applying for openings. "This contributed to reduced quality of medical services" of the Washington facility, the IG said, particularly for veterans in the assisted living and long-term care units, which includes the dementia unit.
-- Bryant Jordan can be reached at firstname.lastname@example.org