First off, full disclosure. 

I receive care at a VA facility. I have never met a more caring bunch of clinicians than those in my health care team. I am a satisfied patient and happy that I have a place to go that specializes in veteran care. The VA here in SLC is a damn good VA.

I am also not so naive to think that there aren’t crappy VA facilities. Just like any hospital chain has crappy hospitals. So, yep, the VA is in the news again. This time with a tale that astonishes me as much as anyone else. 

Ok, no, after this year, nothing astonishes me anymore. So here is the jist from WaPo

In her three years as a nursing assistant on the overnight shift at the local Veterans Affairs hospital here, Reta Mays tended to elderly veterans with the ailments of old age. She took their vital signs and glucose levels on the graveyard shift, sitting vigil at their bedside while medical staffing was thin. Few saw her go in and out of patients’ rooms.

No one watched while she injected them with lethal doses of insulin during an 11-month killing rampage in 2017 and 2018, which she admitted to Tuesday in federal court, pleading guilty to second-degree murder in the deaths of seven veterans and an intent to murder an eighth who died two weeks later.

Wow, so immediately everyone is screaming, “the VA needs to be fixed,” “How dare they mistreat veterans.” Oh, and my absolute favorite one, “the whole system is broke.”

So to answer those points. 

The fix the VA needs is proper funding to do the job in its facilities, not farming cases out and spending millions more than doing it in house (the private sector is fucking greedy, look at the Covid stimulus money). They need to spend the money to make sure that their facilities remain top-notch, and we need the government’s support to provide more than just lip service to veteran health care. There is no point in privatization since those costs are astronomical. There are already systems in place regarding new hires and credentialing; they should use them.

The VA doesn’t mistreat veterans, this act was criminal and prosecuted as soon as it was discovered (even with an avoidable delay). The deaths, while unexpected, were subtle. Criminal intent is often one of the toughest things to find because we are not expecting it from persons that devote lives and careers to the care of others. I am a vet, and anyone who knows me knows I can be difficult. I can be an asshole and called such today. I can be rough on staff, but the staff knows veterans and treats them as such. There is a real connection at the VA between vets and caregivers.

The system isn’t broke. 

Yes, this should not happen at a hospital, or anywhere. One incident does not mean a broken system, but a closer look is always prudent and can “fix” intact systems. 

Now, this isn’t a total pass. 

There was a lot that was just plain wrong.

The hospital has come under fire for leaving its insulin supplies so easily accessible and failing to more quickly detect the suspicious pattern of the deaths, issues Missal (inspector general) said would be addressed in an upcoming report.

Yeah, in my hospital, your badge determines what area you have access to. There was a lapse in security here.  

Even better is

Mays, hired by the Louis A. Johnson Medical Center in 2015 with no certification or license to care for patients, chose victims admitted to the hospital from July 2017 through June 2018 with heart conditions, strokes, cancer. A few had mild diabetes. But they were not about to die, court documents show.

In the middle of the night, with a small staff on the medical-surgical ward known as 3A, Mays injected the patients with insulin she was not authorized to administer, leading to their deaths from severe hypoglycemia or low blood sugar, investigators said.

All of this is a major fuck up. A criminal act shouldn’t happen anywhere, but it did. I am by no means a VA apologist, but the reason it is making national news is the letters V and A. Fixing this now is the critical part.  

Every hospital has policies and procedures for everything from what can be on a ward’s bulletin board, to dress code, to med room access, to you name it, there is a policy for it (yep even hand washing after using the bathroom).

The facility requires a tune-up, reinforcement of policies, and restriction of access to those with no business in an area. It needs CCTV cameras in controlled areas repaired. It requires that licensed staff perform their duties and not just do their nails at the desk and read People Magazine (c ‘mon, at least cover it with a nursing journal).

It requires vetting potential employees properly and not skipping that step. Although many VA’s do internal skills checks and can have nursing assistants that are not necessarily CNAs, there is still a training and skill sign off. At no point is a nursing assistant allowed to pass or give medications. However, we all know this was a crime, not an effort to have an assistant pass medications as a shortcut (a practice that would be a far worse discovery)

It requires nurses, doctors, and administrators, to supervise those with a lower level of licensure and delegate authority properly. My question, where was the nursing staff? The quote, “Few saw her go in and out of patients’ rooms,” is disturbing. I know, even as tough as it could be, where my LPNs and CNAs were on shift. 

It is part of the responsibility that comes with a nursing license, sorry.

The VA is still safe; it’s still the best care anywhere.

Be the kind of person your dog and your mom hope you are.