The federal government's Office of Special Counsel has reported to the White House that a Department of Veterans Affairs hospital in Jackson, Miss., has allegedly committed "serious wrongdoing" in the care of its patients.
Since 2009, five "whistle-blowers" at the G.V. ("Sonny") Montgomery VA Medical Center in Jackson have made a variety of allegations, including the use of non-sterile scalpels and bone cutters, and missed diagnoses of serious – sometimes fatal – illnesses.
The violations were described in a letter written by Special Counsel Carolyn Lerner and sent to the White House on March 18.
"The VA needs to get it right this time," American Legion National Commander James E. Koutz said. "Over the past four years, VA has investigated the Jackson hospital more than once. They claimed to have taken steps to fix the problem back in 2009. But four years later, our veterans are still at risk because of gross incompetence."
In 2011, another whistle-blower raised concerns about the quality of health care being delivered to veterans in Jackson. Last January, a doctor at the hospital alleged that thousands of X-rays were improperly read, resulting in missed diagnoses of "serious and, in some cases, fatal illnesses," according to Lerner.
"Do we know if the managers who were at the Jackson hospital in 2009 are still there?" Koutz asked. "Maybe VA needs to shake up its leadership there, and find someone who will dismiss medical staff that fails to sterilize equipment properly, or who can't read X-rays properly."
Lerner wrote that she was "deeply concerned that these cases are representative of more pervasive challenges and threats to patient care at the Jackson Medical Center.... Over a period of three and a half years, a diverse group of five employees disclosed serious wrongdoing at this facility."
"This is precisely why we have our System Worth Saving Task Force," Koutz said. "This is why we send task force members to interview administrators and medical staff at VA medical centers across the country – to make sure they aren't doing what apparently has been done in Jackson for the past four years."
Koutz noted that Congress has been examining the way VA processes disability claims for veterans, and what is being done to reduce the backlog. "Maybe Congress should go down to Jackson and find out what's been going on for the past four years," he said.
The Legion's System Worth Saving (SWS)  program was created in 2003 to evaluate VA's health-care system and submit findings and recommendations annually to VA leadership, the White House and members of Congress.
Since then, SWS teams have encountered problems with sterilization procedures during site visits to VA facilities in Miami, St. Louis and Dayton, Ohio. Two weeks after the St. Louis visit, the VA hospital cancelled surgeries after water spots were found on medical trays and equipment.
In 2010, VA created a new office to oversee sterilization processes and dedicate more training and resources to ensure that reusable medical equipment was being properly cleaned.