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The Roseburg Veteran’s Affairs Medical Center emergency room entrance appears in this March 2018 photo. It was converted to a 12-hour urgent care facility beginning Aug. 16.

After a year-and-a-half wait, The News-Review has received a copy of a report by federal investigators looking into concerns about the Roseburg Veterans Affairs Medical Center’s former emergency department operations.

The report received last week wasn’t the one the newspaper expected to get when it filed a May 2018 Freedom of Information Act request, but the report did answer some questions raised at the time.

The newspaper sought a copy of an Office of Medical Inspector’s report based on investigations that office made of the Roseburg VA in late 2017. The OMI had released a two-page summary of its report in early 2018, but never made the full report public.

What the newspaper received instead was a report to the U.S. Department of Veterans Affairs Office of the Special Counsel. This report, dated Jan. 7, 2019, contained information gathered through 2017 and 2018 federal investigations of the Roseburg VA.

Most of the report details the Office of Special Counsel’s reasons for rejecting an anonymous whistleblower’s claim that a policy change was harming VA patients with advanced or terminal illnesses.

However, the report also confirms newspaper reporting from early 2018 suggesting previous administrators had been turning away high-risk patients from the emergency department to manipulate statistics used to determine the hospital’s star ranking — reporting that the Roseburg VA’s then-director Douglas Paxton called “absolutely false” and “fake news.”

Both the emergency department and the star ranking system have since been scrapped. Roseburg VA spokesman Tim Parish noted the report found no patients had been harmed, and that it focused on events that occurred when the facility was under previous leadership.

“Since then, the Roseburg VA Health Care System has made many improvements, including the addition of urgent care services, which average 32 patient visits each day, compared to 31 ER visits each day before August 2019. Additionally, 98% of claims submitted for ER visits through our Office of Community care are being covered,” Parish said in an email.

The report does, however, offer a window into concerns about patient safety that pitted medical professionals against management when Paxton was director.

The Office of Special Counsel report said in 2017 “bed control teams” routinely decided whether patients should be admitted to the emergency department and had the power to overrule emergency doctors’ determinations about whether admission was in the patients’ best interest.

The bed control teams included nurses and administrators who did not have the credentials necessary to practice inpatient medical care. Investigators determined the bed control teams’ purpose was to make admissions decisions that would improve the metrics used in determining the facility’s star ranking. At the time, the Roseburg VA was rated a one-star hospital, the lowest possible ranking.

As The News-Review reported in 2018, investigators also found that the leadership created a toxic environment in which staff members felt too intimidated to report concerns about practices impacting patient safety. Based on investigators’ recommendations, several top officials were removed from supervisory positions. According to the report the newspaper received last week, the bed control teams were also eliminated based on investigators’ concerns. Paxton left the directorship in February 2018.

Dave Whitmer was brought in as an interim director following Paxton’s departure and raised the rating to two stars. The federal VA system abandoned the star ranking program in 2019. Current Roseburg VA Director Keith Allen closed the emergency department and replaced it with a 12-hour-a-day Urgent Care center in August 2019.

The other issue addressed in the Office of Special Counsel report involved a 2018 decision to rescind policies around the treatment of patients with advanced or terminal diseases. An anonymous whistle-blower alleged the change compromised patient care and contributed to an increase in unexpected deaths, measured by the VA’s Standardized Mortality Ratio. The ratio measures the number of deaths that actually occur within 30 days of admission to the VA hospital compared to the number of predicted deaths.

The report said VA investigators visited Roseburg in October 2018 and reviewed 12 cases provided by the whistle-blower in which patients had died. The deaths had occurred over a three-month period in 2018 and were double the death rate of the previous six months.

The investigators found no evidence of substandard care, and the report said the ratio statistic was skewed by two factors — increased admissions after the bed control teams were discontinued and the timing of consultations with patients about end of life care.

Reporter Carisa Cegavske can be reached at ccegavske@nrtoday.com or 541-957-4213.

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Senior Reporter

Carisa Cegavske is the senior reporter for The News-Review. She can be reached at ccegavske@nrtoday.com or 541-957-4213. Follow her on Twitter @carisa_cegavske

(2) comments

chicagomike

I've had several discussions with Director Allen who continues to defend the broken Roseburg VA rather than fixing the problems. This last December, one Veteran whom I'll call Lump was brought into Roseburg's Brookings VA walk-in clinic by myself and another Veteran because Lump wasn't feeling well. After having to wait for over a half hour, the VA nurse called Lump, didn't triage or check vital signs and instructed us to take Lump to the Urgent Care. (note: according to the VA, the walk-in clinic is considered urgent care. the Mission Act's Urgent Care standard is in addition to the VA's walk-in-urgent care clinics.). When we reported to Curry Medical Center in Brookings and gave them the same symptoms provided to the Brookings VA clerk when Lump first checked in, he was immediately put into a wheel chair and wheeled back into the ER where a team simultaneously hooked him up to an EKG, started an IV took his vital signs, drew blood and asked questions.

The ER Team recognized the signs of a heart attack. The delay incurred could have killed Lump.

This unnecessary delay is reminiscent of what happened to Veteran Ray Velez in 2013, the Roseburg VA killed this Veteran who died en-route to Eugene when VA docs failed to provide life saving care.

Lump, Myself and another Veteran have a meeting scheduled with Director Allen and Brookings Nurse Manager Chris Ihle to discuss this and other problems at the Brookings clinic on February 19th prior to the Brookings town hall. I have a follow up call scheduled with Senator Merkley's office on February 20th.

The systemic failures of the Roseburg VA are wide ranging and go beyond failing to: meet required staffing requirements, providing mandated medical screenings, same day mental health services, provide FDA mandated prescription drug label warnings and Black Box warnings, providing Veterans with diabetes mandated annual foot inspections and podiatry care, properly document medical conditions in Veterans medical records problems lists to alert the high turnover of PCPs (I've had 7 since 2016) of medical conditions that identify Veterans where follow up care is needed and what drugs should not be prescribed-what follow-up screenings and imaging studies are needed, etc., etc., etc..........

When reading in VHA directives and handbooks the standards of care the Roseburg VA Health Care System is required to provide to Veterans and is not, Roseburg VA gets an "fail" grade. OIG-OHI inspections that look at all of these systemic failures-documented in Veterans Medical Records, is needed. The last inspection documented the radiology departments failure to have a peer review process to detect image quality problems and the accuracy of radiologists reports but failed to actually examine Veterans imaging studies which shows severed tendons intact, Brain Cysts seen the day before at CMC which disappear from Roseburgs 12 year old, defective MRI machine the next day and then re-appear on a followup MRI at Providence three months later. There are numerous examples of these radiology failures, where arthritis disappears from Roseburg's MRI and then re-appears on non-VA MRI scans. Etc.

The former Chief of Radiology Spencer Wang (RIP), whom I had spent over three hours with reviewing Roseburg's flawed MRI studies, the dark and blurry images that contributed to these flawed studies, wanted a new MRI machine admitting that the studies produced on newer non-VA MRI were high quality images compared to Roseburg's. Patient Advocate Kara Coffland informed of Roseburg's MRI that it was to "too old" to set individual patient parameters to achieve fat and water separation from images to provide clear imaging.

Whitmer promised to make the high tech/high cost replacement request for Roseburg's MRI at two town hall meetings and prior to that, sent me an email link to the West Palm Beach, FL about his success as associate director replaced the aged, small bore MRI with newMRI scanners that produced high quality Images.

Director Allen informed at the Brookings town hall last June, In the context of how many of Roseburg's Vietnam Vets would be alive in ten years, stated he would not make the request to replace the MRI as he needed to strike a balance with meeting of the future needs of the Roseburg VA. Spoken by Community Care's Rocky Phillips at the Nov 2019 town hall in Brookings, which I re-iterated last December at the Roseburg Town hall, 65% of Roseburg's Veterans are over the age of 65. This age group of Veterans are the targeted group of many of the medical screenings the Roseburg VA does not provide to Veterans.

In a July letter to Senator Merkley, Director Allen states he is committed to providing Veterans the "World Class" healthcare they deserve but admits Roseburg's failure to offer Lung Cancer Screening as well as denying aqua therapy to a Veteran, stating in another letter that it is not a modality of care even though it is prescribed for other Veterans and is even advertised on the door of Roseburg VA's Physical Therapy Department.

Director Allen, I certainly hope our discussions lead to better medical care for Veterans which is the duty you have been charged with providing.

Mike Berns

Mike

It appears the VA protects and covers for their problem personnel. Rather than addressing the problem, it appears the VA simply moved Doug Paxton to a new location where he will have the opportunity to recommence the same problems.

According to Doug Paxton's Linkedin on-line profile, he is Associate Director of the Department of Veterans Affairs in Odessa, Texas.

Odessa

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