Sens. Joe Manchin and Shelley Moore Capito and Rep. David McKinley joined Veterans Affairs Secretary Denis McDonough at the Clarksburg VA hospital Monday for a tour and a discussion of the failures that allowed Reta Mays to murder eight patients.
McDonough read the names of the eight victims during a press conference that followed the tour. “No words can ease the pain or the suffering and losses for families, caregivers and survivors, ” he said. “VA must accept some responsibility, which we have done and will continue to do.”
Through the Office of Inspector General Report issued last week and supporting evidence, he said, they have a detailed understanding of the failures. “We will take every step possible, we will spare no resource to prevent this from ever happening again.”
McDonough praised the staff, many of them veterans, for their work, and acknowledged many feel hurt and betrayed. “This crime does not define you.”
Manchin and Capito both said there remains a need to expedite closure for other families that still don’t know if their veteran was also a victim.
Manchin serves on the Armed Services Committee and said they were asked by the judiciary not to probe the matter until after Mays’ sentencing. Now that hearing will go forward and the results will be released to the public.
He and his colleagues, he said, will keep watch on the VA to ensure change. “We want this to be the gold standard and we’re going to correct this.”
What happened here “shakes the entire country … and it can’t be tolerated, ” he said. “We’re going to hold all of you to a higher standard. We know you can do better and we know you will be better.”
Capito said they will hear from many employees in the facility and they will get a good measure of the people who work there. “We want to restore confidence and the morale.” They want to help not just Clarksburg but the VA in general correct “some egregious mistakes.”
McKinley said, “The point now has to be how we restore hope and confidence in the system ” by holding McDonough and the VA to accountability. “They have faced evil. That was the last thing they thought, that they would face evil in this hospital. We’ve got to give them confidence things are fine.”
Former nursing assistant Mays was sentenced last week to seven life sentences plus 20 years for killing eight patients at the Louis A. Johnson VA Medical Center with lethal doses of insulin.
The 100-page OIG report cited leadership failures at multiple levels that failed to consistently promote a culture of patient safety, including: failure to review personnel records and do background checks ; inadequate medication security ; clinical failures to investigate the occurrences of hypoglycemia that killed the veterans, including inadequate or nonexistent documentation ; and failures in staff monitoring and oversight.
McDonough fielded a question about reports circulating that at least 21 families whose deaths may be suspicious have not been notified of an investigation.
He said, “I welcome the opportunity to hear from the families if there is a concern about that.” The OIG reviewed more than 200 cases and recommended that the regional VA office look at any of those files they have reason to question ; about 197 have been shared to outside experts. They will examine those cases and contact families as appropriate. He didn’t say directly but indicated not all of those are deaths, just potentially suspicious occurrences.
Asked if anyone has been fired, he said they just received the OIG report a few days ago and will take quick action to hold those accountable who did not meet VA standards.
Some people have been removed from their positions, he said, and others have filed their own retirement. News reports have said several leaders were shuffled to other VA jobs, including former director Glenn Snider Jr.
Manchin said the Armed Services Committee will find out who’s been shuffled or may be still getting a pension.
Capito has said more than once that the VA needs some reform across the board and The Dominion Post asked Monday if the Clarksburg failures represent systemic problems.
He said, “We’re also a learning, responsible organization that’s going to ask hard questions ” and use data to make sure they’re meeting standards, including in hiring, training, pay and investing in personnel growth. “We’ll continue to learn from that.”
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