At least three patients at the Cincinnati VA Medical Center died due to lapses in care while another unattended patient attempted suicide between 2017 and 2020, the VA’s inspector general reported this week in a tough report on the facility’s operations.
Officials did not properly document what happened to the four patients. Cincinnati VA officials also did not tell the patients’ families whatever occurred to their loved ones, according to the 85-page report released Wednesday. Scroll to the bottom of the story to read the full report.
The hospital’s overall system of examining the root causes of problems had gaps, as well, the report said. Asked about the lack of data, a hospital official “reported not fully understanding that the series of ‘why’ questions were to be documented … when these reviews were completed.”
The inspector general’s examination also found the front office of the Cincinnati VA, which has been shifting for at least five years, remains in turmoil. When Veterans Affairs' investigators made a virtual site visit in July, three of the four top managers were working in an acting capacity.
One job, in charge of patient care, “has been filled temporarily by four separate medical center staff," the report noted. "In addition, six different employees had served as the acting chief of staff since the position became vacant in May 2019.”
