July 24, 2024

Gallego Demands Answers, Accountability Following VA OIG Report on Phoenix VA

WASHINGTON – Today, Rep. Ruben Gallego (AZ-03), sent a letter to Dr. Shereef Elnahal, Under Secretary for Health at the Department of Veterans Affairs (VA), demanding answers and accountability in response to the VA Office of Inspector General (OIG) report Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona.

“As an elected representative of Arizona’s veterans, and as a combat veteran who has received care at the VA myself, I was appalled to learn of the inexcusable failures that led to the death of a veteran, and of the apparent lack of accountability at the Phoenix VA Medical Center in my district,” Rep. Gallego wrote.

He continues, “As is so often the case, it was not a single failure, but multiple failures to take simple actions and implement commonsense procedures which led to this tragedy. Additionally, the failure to properly document the incident in the Joint Patient Safety Reporting System may be just as egregious. Because the incident was not properly recorded and investigated as soon as it occurred, the same deadly vulnerabilities remained, and this tragic incident had the potential to repeat itself.”

To understand how this incident was allowed to occur and prevent it in the future, Rep. Gallego requested a briefing and demanded answers to the following questions:

  1. How many total veterans received care at the Carl T. Hayden VA Medical Center between the death of this veteran last year and the publishing of today’s OIG report?

  2. Why was an AED not in a highly trafficked area until after this event?

  3. For which VA personnel is CPR training mandatory, and are there requirements or policies to have CPR-trained personnel in patient settings?

  4. Why did the operator not automatically connect callers with the VA Police during a medical or other emergency?

  5. Is it a requirement for all emergency calls to be properly logged, including the identity of the operator?

  6. If a call is improperly logged or is not logged at all, either accidentally or purposefully, what is the VA’s policy? Is there a formal investigation? Would such an investigation include federal, state, or local law enforcement?

  7. Is it VA policy to check vitals before every medical appointment? If not, what is the policy? If so, why did the patient’s care plan not include this seemingly basic protocol?

  8. Is it required procedure to file an incident report in cases like this, and, if so, why does it appear that no incident report was filed?

  9. Has anybody been held accountable for the death of this veteran, and, if so, how?

  10. What is the timeline for implementing the recommendations of the OIG report, and what are you doing to ensure these recommendations are followed?

Full text of the letter can be found HERE.

The letter comes after Rep. Gallego released a statement immediately following the report’s release earlier today.