A report was released Tuesday outlining a long list of failures at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia that led to the deaths of at least seven men.
The report, from the U.S. Department of Veteran’s Affairs Office of Inspector General, was released on the same day 46-year-old Reta Mays was sentenced to seven consecutive life terms plus 20 years for the killings of the veterans, states that Mays bears the ultimate responsibility for the murders — but also notes missteps by leaders of the facility.
“The OIG found that the facility had serious, pervasive, and deep-rooted clinical and administrative failures that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier,” the report states. “The failures occurred in virtually all the critical functions and areas required to promote patient safety and prevent avoidable adverse events at the facility.”
As she accepted a plea deal in July, Mays admitted to seven counts of second-degree murder and one count of assault with intent to murder the veterans. She unnecessarily administered insulin to the men, causing sudden hypoglycemic events that ultimately led to their deaths.
Investigators with the Office of Inspector General concluded in the report that there were deficiencies in the hiring of Mays, the evaluation of her performance, the management and security of medication, clinical evaluations of the at-the-time unexplained hypoglycemic events, the reporting and response to the events, as well as the response and corrective actions taken by leadership of the facility.
At a news conference following Mays’ sentencing, VA Inspector General Michael Missal pointed out that the former nursing assistant won an award for her work, but should not have — noting one of the many missed opportunities to identify the issues that came up over the course of her tenure at the facility.
“She actually received a Secretary’s Award for Excellence in 2017,” Missal said. “As part of receiving that award, they were required to go back to make sure that her background check had been done. They checked it had, when it actually hadn’t.”
West Virginia’s two U.S. Senators — Democrat Joe Manchin and Republican Shelley Moore Capito — both made comments Tuesday to news media about the report’s findings.
“I just think there’s just an absolute lack of accountability — or total lack of accountability — of the Clarksburg VA. There’s no other way to put it,” said Manchin, a member of the Senate’s Committee on Veterans’ Affairs, during a Tuesday conference call with reporters. “The people that have been in charge there should no longer be in the VA system, as far as I’m concerned, with the total disrespect they had for the well-being [and] welfare of our veterans. And I think that shows up loud and clear in the OIG’s report.”
Manchin noted that he was unable to disclose many details about the VA hospital until the investigation had concluded.
“The shackles are off and I can guarantee you we’re going after them hard, very hard,” he said.
In a statement released Tuesday, Capito also expressed concern over the report, which she described as “devastating.”
“The failures at the Clarksburg VAMC outlined within this report are absolutely unacceptable,” Capito said. “The findings show a collapse of administrative and clinical responsibility that has led to unimaginable consequences, which makes it clear that updated policy and procedure is desperately needed.”
Capito said she is committed to seeing to it that the recommendations included in the report are implemented and that leaders at the VA are held accountable for the failures that took place.
“Our veterans in West Virginia deserve the highest level of care possible, but they also need to be able to trust that they will be safe and protected under the care at our VAMC facilities,” she added.
According to the report, the OIG made recommendations across various departments and functions of the facility in question and the agency at large, aimed to enhance patient safety — including medical chart audits, checks and balances within pharmacy quality assurance processes and quality management reviews.
Wesley Walls, a spokesman for the Louis A. Johnson VA Medical Center, issued a statement expressing a need to rebuild the trust of veterans seeking care at the facility.
“While this matter involving an isolated employee does not represent the quality health care tens of thousands of North Central West Virginia Veterans have come to expect from our facility, it has prompted a number of improvements that will strengthen our continuity of care and prevent similar issues from happening in the future,” Walls said.
Walls said recommendations are currently being implemented and will be complete by March 2022.
