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Hon. Mike Coffman

Hon. Mike Coffman, Chairman, Subcommittee on Oversight and Investigations

Good morning. This hearing will come to order.

I want to welcome everyone to today’s hearing titled, “Correcting ‘Kerfuffles’ – Analyzing Prohibited Practices and Preventable Patient Deaths at Jackson VAMC.”  I would also like to ask unanimous consent that several of our Mississippi colleagues be allowed to join us here on the dais to address issues very specific to their constituents.  Hearing no objection, so ordered.

Today’s hearing is based on serious allegations of wrongdoing at the G.V. Sonny Montgomery VA Medical Center in Jackson, Mississippi.

Despite systematic problems at Jackson, VA has maintained that any concerns have not had a negative effect on patient care.  For example, the VA Undersecretary for Health, Dr. Robert Petzel, made the following statement in an apparent attempt to downplay the myriad issues at Jackson VAMC. 

(Video clip)

This clip represents the attitude of VA following years of prohibited practices at Jackson that have negatively affected care provided to veterans.  That negative effect is apparent in the tragic story of Johnnie Lee.

Johnnie Lee, an Army veteran and longtime employee of Jackson VAMC, became a casualty of inept supervision and inadequate staffing on the part of facility officials.  According to whistleblower reports, Mr. Lee went to Jackson VAMC for a routine skin graft operation in April 2011.  Following the operation, he was attached to a negative pressure wound therapy machine (often referred to as a “wound vac”) that is designed to remove fluids from sealed wounds. 

Mr. Lee was then left unattended and connected to the wound vac for a number of hours.  When Jackson personnel finally returned to check on him, he was dead, his body having been drained of all its blood, which spilled out onto the floor of the room. 

Months prior to this horrible incident, the FDA released a safety report on wound vacs requiring frequent monitoring of patients with a specific caveat to “[b]e vigilant for potentially life-threatening complications, such as bleeding, and be prepared to take prompt action if they occur.” 

Mr. Lee’s death would have certainly been prevented had Jackson VAMC officials heeded this warning, properly informed and supervised its personnel, and monitored Mr. Lee appropriately.

Today, we will discuss the many serious issues that continue to plague Jackson VAMC. 

Understaffing of personnel has led to the overreliance on nurse practitioners, resulting in many veterans not getting access to an actual doctor during their care at Jackson and nurse practitioners operating without supervision. 

The routine practice of booking multiple patients for single appointment slots leads to patients being turned away without service. 

Thousands of radiology images have gone unread or improperly read, resulting in missed diagnoses of serious, and in some cases fatal, illnesses.  Jackson VAMC management was aware of these allegations, but only undertook a cursory investigation to address them.

The facility also has narcotics prescription policies in place that led to the August 2012 resignation of the Jackson VAMC Chief of Staff and the May 2012 arrest of the Associate Director for Patient Care Services on a prescription fraud charge. 

Other allegations state that physicians at Jackson VAMC are frequently asked to sign Medicare Home Health certificates on patients they had not seen or for nurse practitioners they do not supervise, which is essentially a commission of Medicare fraud. 

Ultimately, VA has taken inadequate action to hold Jackson VAMC management accountable for contributing to or approving of these systematic problems.  The Office of Special Counsel appropriately stated that the VA investigation into these matters has been “insufficient and unreasonable.” 

In light of the obvious deficiencies we will discuss today, some of which have led to preventable patient deaths such as that of Mr. Lee, it is painfully obvious that VA is not taking the problems occurring at this facility seriously and is showing a lack of commitment that quite apparently affects care provided to veterans.

I now yield to Ranking Member Kirkpatrick for her opening statement.