BUFFALO, N.Y. (WKBW) — The U.S. Department of Veterans Affairs Office of Inspector General released a report Friday which found that leaders at the VA Western New York Healthcare System in Buffalo failed to address patient care concerns.
According to the report, a healthcare inspection was conducted to asses allegations regarding community care consult appointment scheduling practices and delays for patients with serious health conditions.
"The OIG substantiated that community care staff's delays in scheduling patients' radiation therapy and neurosurgery appointments resulted in delays in care, and in some cases, either caused or increased the risk of patient harm. The OIG determined system and community care leaders failed to resolve significant community care scheduling delays for patients with serious health conditions, despite providers' and community care staff's efforts to advocate on the behalf of patients," the report states.
According to the report, 42 patients' electronic health records were reviewed to evaluate how scheduling delays impacted patients and may have resulted in patient harm. It found that all 42 patient consults "significantly exceeded the seven-day Veterans Health Administration (VHA) scheduling requirement." For three of the patients, the delay impacted the provider's management of the patient's condition, and for nine of the patients it impacted the patient's clinical status or condition.
The report provides a detailed review of four of the nine patients cases, which included:
- A patient who had a new cancer malignancy and waited nine weeks for radiation therapy
- A patient who experienced ongoing seizures while waiting 10 months for a neurosurgery consult
- A patient who was at an increased risk of developing ischemic stroke waited 9 months to obtain a computed tomography angiography
- A patient who died while waiting over two months to receive radiation therapy to treat cancer pain
The Office of Inspector General made the following recommendations:
- The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high-reliability organizational principles and take action as warranted.
- The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.
- The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.
- The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.
Local elected leaders voiced the following frustrations with the report that evening:
“This report reveals a horrifying level of negligence that resulted in veterans experiencing significant delays in the care they desperately needed. This is not about a lack of resources—this is about sheer incompetence from leadership at the Buffalo VA that left veterans to suffer and, in some cases, lose their lives. I spoke with VA Undersecretary Dr. Shereef Elnahal, who confirmed there will be a disciplinary hearing for those responsible, and I have confidence in his ability to get the Buffalo VA back on the right track. Above all else, we must follow up on real reforms to put veterans first, so they get the timely, quality care they deserve.”
“The egregious neglect and failure of the Buffalo VA leadership outlined in this report is infuriating and inexcusable. Their repeated inattention to provider and patient outcries has led to American heroes being abandoned by a system meant to serve and protect them. This is a complete disgrace and a betrayal to the women and men who have made incredible sacrifices to safeguard our nation.
Immediate reforms are necessary to ensure that Western New York veterans receive the care, support, and respect they have earned and deserve. Implementing the recommendations in the report is a first step. I am calling for further Congressional oversight, up to and including an investigation, to ensure this failure in care never happens again.
I will not rest until the Buffalo VA has the leadership, staff, facilities, and funding in place to deliver the care that our veterans who have sacrificed so much for our country have earned and deserved.”
We spoke with Langworthy and Kennedy after the report was released, you can watch our full report below.
This is a story we have been following for the last few months. In August, Assemblyman Pat Burke invited veterans for a roundtable discussion of concerns over care at the Buffalo VA Medical Center.
"There's a backlog. Staffing is overwhelmed. A lot of veterans' issues aren't really handled. They get pushed back," Bernie Romanowski said. You can watch our previous report below and read more here.
A few days later, the Medical Center Director and its Chief of Staff were removed by the Department of Veteran's Affairs, pending an investigation. You can watch our previous report below and read more here.
A few days after the Medical Center Director and its Chief of Staff were removed, nurses railed outside of the medical center holding signs and chanting — calling for more staff and equal pay. You can watch our previous report below and read more here.
