Earlier this week, outgoing chairman of the House Veteran Affairs Committee, U.S. Rep. Bob Filner (D-Calif.), returned to the John Cochran VA Medical Center in St. Louis to speak to patients and staff about ongoing patient-care issues. Filner and U.S. Rep. Russ Carnahan of Missouri toured the facility to get a better understanding of the allegations put forth by nurses in the medical center's telemetry and intensive care units, including a chronic lack of response from management to their concerns about absent or broken equipment that impact patient safety, as well as staffing levels, and other issues.
"People don't go into nursing because they want to make money," says Wes Gordon, a veteran and telemetry nurse at Cochran. "They do it because they care about people, they care about their patients. And these veterans deserve the very best care possible."
According to a statement issued by Carnahan's office, some of the problems detailed by the nurses include:
- Lack of disposable personal protective equipment (PPE) and other supplies in isolation rooms to help prevent the transmission of infectious diseases from one patient to another
- Equipment, such as oxygen tubing for respiratory assistance, is chronically broken or unavailable
- Tools that could provide time-critical diagnoses, such as fundoscopes, are unavailable, despite more than three years of regular requests
- Too few nurses and nursing aides are assigned to too many patients, compromising nurses' ability to provide proper care and resulting in patients going days without baths or clean linens.
According to Carnahan's statement, Gordon presented hundreds of e-mails he had sent to management requesting their attention to these and other problems over the past year - many of which had gone unanswered. He noted that even the simplest of requests -- applesauce for patients who cannot swallow, and thus need medication ground into soft food -- took more than two years to be addressed. And when he brought in his own supply of applesauce, he was immediately reprimanded.
"This is unacceptable in an organization that is supposed to be patient-focused," says Carnahan, who has called for multiple investigations in the wake of sterilization problems at the Cochran dental clinic that potentially exposed more than 1,800 veterans to bloodborne diseases. "I have been pleased with some of the improvements that have been made in the sterilization process, but it would appear that incident was a symptom of a much larger problem," Carnahan says. We can't be satisfied with small changes around the edges. We have to get to the bottom of this so that we can make the fundamental changes that clearly are necessary to make sure veterans get the care that they deserve."
Glenda Skinner, another nurse and veteran who spoke at Tuesday's meeting with Filner and Carnahan, said that she had worked at other VA Medical Centers, and that the contrast in quality was stark. "I hope this is the end of where we have been and the beginning of better care for these patients," Skinner says.
After the meeting, Carnahan and Filner traveled to the Cochran Medical Center for a tour, during which they promised to press Cochran officials about some of the concerns expressed in the meeting.
Carnahan said that reports from the two independent bodies investigating problems at Cochran - the Inspector General and the Government Accountability Office -- were expected to be made public by mid-spring. A third, internal VA investigation, was reportedly concluded in November, but has yet to be made public, a problem which Carnahan and Filner pledged to rectify, according to Carnahan.
Carnahan also indicated that he had talked with incoming House Veterans Affairs Committee Chairman Jeff Miller (FL-01) about holding a follow-up hearing in St. Louis when the results of those reports are made public.
Filner, who was Chairman of the Veterans Committee for the 110th and 111th Congress, urged the media to make sure that Gordon and the other nurses did not suffer retribution for coming forward. "As Members of Congress, we can't exercise oversight without information," Filner said. "We need brave people like this to come forward and tell us what is really happening. They shouldn't be punished for trying to make sure those veterans get the care they deserve."