VA hospital officials knew of problems, did nothing, Murray says

Officials inside the local veterans hospital knew some conditions were unsafe for suicidal or homicidal patients in February, but ignored recommendations in their own internal audit, Sen. Patty Murray said Friday.

Murray, D-Wash., flew in Friday from Washington, D.C., to tour psychiatric wards at the Beacon Hill hospital operated by VA Puget Sound Health Care System.

The system in May flunked an inspection by the Chicago-based Joint Commission on the Accreditation of Health Care Organizations, which issued a "preliminary denial of accreditation." That report cited conditions in psychiatric wards in Seattle and American Lake that posed "a serious threat to public or patient health or safety" because they might allow patients to kill themselves or hurt others.

In a news conference after her tour, Murray said she believes officials are now convinced of the seriousness of the problems identified by their own staff and Joint Commission inspectors, and are actively working to correct them. Those problems include fixtures and furniture that could be used by suicidal or homicidal patients, as well as deficiencies in the health system's assessments of patients' risk.

"I know that the VA officials that were here today understand the gravity of the situation," she said.

Indeed, said Stan Johnson, acting director of the Puget Sound system, "We take this very seriously," and will make requested changes in a "timely and comprehensive manner."

Even so, Murray said, she was "very sad" to find uncorrected problems four years into the Iraq war. "It's deeply disturbing to me that the VA continues to be behind the eight ball."

An estimated 40 percent of those returning from conflicts in Iraq and Afghanistan are experiencing intense mental problems, such as post-traumatic stress disorder (PTSD) and traumatic brain injury, "and our country has to be ready for them," she said.

"I am deeply concerned by the reports we have been getting for some time now that we are not prepared for the kinds of mental-health wounds that are coming home from this war."

Despite the problems cited in the Joint Commission report, many patients and families praise care received on the Seattle hospital's psychiatric wards.

"They do everything in the realm of possibility to help us here," said Dennis Palucki, 27, who checked himself into the PTSD ward Monday. Palucki, who returned last fall from a tour as a combat infantryman in Iraq, said he was grateful to find he could get care at the VA for problems such as nightmares and "hypervigilance" that have prevented him from working.

BeeBee Burns, whose Vietnam-vet brother spent three weeks in the psych wards last summer, said she was hurt to learn the hospital was in trouble.

"There is no more dedicated staff anywhere," she said. "We are so fortunate to have them; they get so little recognition and they work so hard. ... They are doing a wonderful job."

Murray on Friday also praised the "high number of dedicated professionals" at the VA.

Still, she added, there have been two suicides in psych wards in the system — one at Beacon Hill last fall, in which a patient hanged himself from the grab bars in a bathroom, and another at American Lake about two years ago. According to the report, there was also a recent attempt there.

The suicide at the Seattle hospital prompted an internal audit in February, Murray said, and recommendations were made to remove or change some fixtures, such as ceiling sprinkler heads that could be used in a hanging attempt, or under-sink plumbing that could be used for asphyxiation.

But the staff's own recommendations were not followed, Murray said, "and that was a mistake on everyone's part."

There is no excuse for not following up, she said.

Joint Commission inspectors, when they visited in May, were clearly struck that the hospital had made no changes to problems it had identified in its own audit. The VA "elected not to correct" the problems, the inspectors wrote, and there was no evidence it planned to do so or take interim measures "to protect patients at risk."

The commission meets again in August to issue final findings, Murray said.

"This is something I'm going to follow up on," Murray said. "Let me tell you, I am not going to let this go. ... I will be back here again to see for myself that those recommendations are implemented."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com