Update: Dayton VA Medical Center Scandal


The last update we did on the Dayton VA Medical Center Dental  Clinic Scandal was posted on 7 April, Ohio Politicians Refuse to let the VA scandal go away!

Since that update, instead of the scandal simply going away, we have witnessed (1) the scheduling of a U.S. Senate hearing next week on Tuesday 26 April, and (2) reports in Dayton Daily News and local TV station news that both patient and VA employee satisfaction with the Dayton VA Medical Center falls below that of other Department of Veterans Affairs Medical Centers.

See detailed stories below.

ROBERT L. HANAFIN, Major, U.S. Air Force-Retired, U.S. Civil Service-Retired, Veterans Issues Editor, VT News Network

Dayton VA Medical Center to get Senate hearing

Session April 26 to key on how to move forward in wake of dental clinic scandal.

Source: Dayton Daily News Staff Writer Ben Sutherly,

Updated 10:19 PM Tuesday, April 12, 2011

According to the Dayton Daily News, and Dayton area TV stations, a U.S. Senate hearing [is] set for 2 p.m. 26 April that will focus on how to move the Dayton VA Medical Center forward following a scandal at its dental clinic.

According to the office of U.S. Senator Sherrod Brown, Sinclair Community College in downtown Dayton is the possible site for the hearing.

Brown, D-Ohio, called for the hearing back on 11 Feb, three days after the Dayton VA offered free screenings to 535 veterans to see if they were infected with hepatitis B, hepatitis C or HIV at the dental clinic over an 18 year period between 1992 and July 2010.

The veterans had received invasive dental work from VA Dentist, Dwight M. Pemberton, who failed to change latex gloves between appointments and did not sterilize dental equipment properly.

Two new former patients have tested positive for hepatitis B, and further testing is under way to try to determine if the clinic was the source of their infections.

A spokeswoman for Senator Brown’s office didn’t have a list of witnesses who will be called to testify at the hearing. But the staffer did say the hearing would include testimony from three or four high-level VA officials who did not have direct oversight responsibilities for the dental clinic at the time of the scandal. The hearing also will include testimony from a representative of the VA’s Office of Inspector General, who will provide findings from the OIG’s yet-to-be-released review of the dental clinic.

Dayton VA employees are also expected to speak, according to Brown’s office.

The hearing will focus on how to move the Dayton VA forward and restore veterans’ and the public’s confidence in the VA hospital system.

“It’s not intended to be a fact-finding, retrospective kind of hearing,” the staff member said.

U.S. Rep. Mike Turner, R-Centerville, has also called for the House to hold a hearing on the Dayton VA, but a Turner spokesman said Tuesday that an official response has not been received.

For questions regarding this Dayton Daily News Report, please contact Ben Sutherly at (937) 225-7457 begin_of_the_skype_highlighting (937) 225-7457 end_of_the_skype_highlighting or bsutherly

Source: http://www.daytondailynews.com/news/dayton-news/dayton-va-to-get-senate-hearing-1134425.html?printArticle=y

Dayton VA hospital’s satisfaction falls below other veteran centers

I initially heard this reported on our local Dayton TV News station this morning then tracked down the source Dayton Daily News Reporter Ben Sutherly

Updated 1:38 AM Sunday, April 24, 2011

As a World War II fighter pilot, Lt. Col. James B. Cheney was taken prisoner and beaten severely by German soldiers with shovels, leaving him with lifelong health complications.

Nearly 65 years later, on 14 Sept. 2009, those old war injuries would come back to haunt the Urbana man when he was physically and verbally abused while seeking treatment at the Dayton VA Medical Center.

Elected officials have sharply criticized the Dayton VA in recent months after the hospital revealed at least 535 patients in its dental clinic may have been exposed to bloodborne pathogens by a dentist who failed to change his gloves and sterilize dental instruments between patients.

The dental clinic isn’t the only aspect of the center to come under fire.

The Dayton VA in general has long struggled with negative perceptions, consistently ranking lower than its peers in surveys of patient and employee satisfaction.

“The needle has started to move, and over the past several rating periods, it has moved up gradually (but) slowly,” said William Montague, who was brought out of retirement to help turn around the Dayton VA in the wake of the dental clinic scandal. “Our goal is to move the needle faster.”

It didn’t move fast enough for Cheney, however.

That September night in 2009 the metal plate in his neck kept his head from fitting into a bracket as two employees prepared him for a CT scan.

A radiation technologist standing behind Cheney placed both hands on the 89-year-old veteran’s forehead, and pressed down with all of her weight, according to Cheney and a nursing assistant who witnessed and reported the incident.

After the incident, Cheney, now 91 and currently hospitalized at the VA for other reasons, told investigators he had a “clicking sound in his neck and trouble swallowing pills,” though there was no medical documentation of those new physical problems, according to VA investigative documents.

“The last thing I expected when I went to get him something to eat was that he would be abused in the hospital where people should be taking care of him,” Cheney’s wife, Linda, told investigators.

A VA investigation substantiated the witness accounts, and the technologist was fired.

Despite some improvements, recent VA surveys find the Dayton hospital still lags its peers in key measurements for patient and employee satisfaction. A fiscal 2010 patient survey found 56.9 percent of patients viewed inpatient quality at the Dayton VA positively, compared to the national average of 63.9 percent. For outpatient quality, the positive response was 54.8 percent, in line with the national average.

Equal Employment Opportunity (EEO) Complaints Filed by VA Employees

The Dayton VA also continues to have a high level of formal equal employment opportunity complaints compared to other VA facilities in Ohio. The hospital logged 75 such complaints between fiscal 2003 and 2007, second only to the much larger Cleveland VA. Between fiscal 2006 and fiscal 2010, the most recent five-year period available, there were 72 such complaints at the Dayton VA. The VA couldn’t immediately provide data last week to allow recent EEO comparisons between VA hospitals in Ohio, but the 72 complaints were only a notch below the previous reporting period.

U.S. Rep. Mike Turner, R-Centerville, said the community has been concerned about the Dayton VA’s low ratings for patient and employee satisfaction, though its actual clinical results compare more favorably. Closing that gap, he said, is Montague’s charge.

“He comes to our facility with a reputation of having turned other hospitals around,” Turner said of Montague. “He seems like the right guy with the right skills with the right commitment.”

Sen. Sherrod Brown said he wants a fuller explanation of the dental clinic’s problems and what’s being done to correct them at an upcoming Senate hearing next Tuesday in Dayton.

Brown and Turner said last week they want testing of all patients of the dentist at the heart of the dental clinic scandal, Dr. Dwight Pemberton. The number of patients is estimated to be at least 2,000 [as compared to the 535 reported by the VA], though the VA has not responded to a request from the Dayton Daily News for the total number of patients seen by Pemberton.

“The Dayton VA has stood out as having problems which other VA centers in Ohio did not have,” Brown said Friday. “They need to restore confidence.”

As the Dayton VAMC Dental Clinic Scandal drew National attention, there has been mixed marks from veterans, and VA employees

The dental clinic scandal has drawn national attention, not only for Pemberton’s gross disregard of infection control protocols, but by the culpability of supervisors in covering up his actions. Discipline is pending for two dental clinic supervisors.

The VA has come under intense criticism from elected officials, particularly Turner, who has requested the House of Representatives hold its own hearing on the matter.

Just last week, a Greater Dayton Area Hospital Association called for the VA to offer testing to at least 2,000 veterans seen by Pemberton. The scandal also led to the reassignment in March of Montague’s predecessor, Guy Richardson, to a job at VA’s regional headquarters in Cincinnati.

“I think the supervision hierarchy has been improved significantly, and it has been made very clear to every individual in that hierarchy what the supervisory expectations are,” Montague said in an interview last week.

“We never want this to happen again. And I believe we have all but ensured that. I cannot guarantee every behavior of 1,900 employees, but I can guarantee you that there is a process that should catch any deviation from expected standards.”


Some veterans claim the troubles in the Dayton VA’s dental clinic involve just a tiny fraction of a large organization whose 1,900 employees capably serve more than 37,000 patients and their families annually.

“Every time I’ve been there, I’ve been treated with respect, kindness, and I’ve been treated with the appropriate medical care,” said Mark Landers, president of the Montgomery County Veterans Service Commission. He said other veterans with whom he’s spoken also have favorable views of the hospital and its services.

Landers noted the VA was an early adopter of electronic medical records, and he said patients are seen in a timely manner.

If veterans have problems with the Dayton VA, the veterans service commission has a statutory obligation to help address the matter, he said.

Denver Combs, who helps veterans navigate the VA system and educate them on their entitlements, said there often seems to be a disconnect between the Dayton VA and the regional VA system. He claimed doctors don’t always have the proper benchmarks before assessing veterans to see if they’re entitled to a greater amount of service-connected compensation. That means backlogs for claims and results in longer wait times, he said.


VA surveys, however, show the Dayton VA ranks slightly above average in how quickly patients perceive they get care — 80.2 percent — compared to the national average of 79.6 percent.

The community needs to be open-minded and careful in judging the Dayton VA based on news reports about its dental clinic, cautioned Herbert Davis, the Montgomery County Veterans Service Commission’s interim director.

“There is a human element in everything that we do, and we occasionally make a mistake,” Davis said. “We have to be mindful that we’re talking about human beings.”

A World War II veteran’s ordeal

James Cheney had been pleased with the care he had received at the Dayton VA — until September 2009.

“All my experience with the hospital has just been superb and people have been nice to me and people have taken care of my problems,” he told VA investigators in 2009. “And Lord knows, I have a lot of them.”

Many of those health problems stemmed from abuse Cheney suffered as a prisoner of war at the hands of German soldiers in 1944. He sustained severe head injuries, and suffers from post-traumatic stress disorder, according to his wife. The installation of a metal plate after a more recent fall left his neck with limited mobility. His legs are permanently contracted. He is a 100 percent service-connected disabled veteran.

On Sept. 14, 2009, Linda Cheney brought her husband to the Dayton VA to be examined for a possible urinary tract infection and/or a nasal infection. The emergency department doctor ordered a CT scan to help diagnose what ailed Cheney. According to a VA investigation summary, the clinical history of the radiology consult for the CT scan contained no documentation of the metal plate in Cheney’s neck and that his neck had limited mobility. According to an eyewitness account from a nursing assistant, the radiology technologist pushed on Cheney’s legs, causing Cheney to yell.

“I told her, ‘You’re being a little rough there,’” the nursing assistant later recalled. “And she said, ‘Well, he was about to fall off the bed.’ And I said, ‘No, I’ve got him.’”

The radiology technologist then again pushed and shoved on his legs.

“You’re hurting me,” Cheney told her.

The radiology technologist then came up to the chest area and tried to convince Cheney to lay his head down.

“He kept telling her that he couldn’t lay it down,” the nursing assistant recalled. After pushing on Cheney’s forehead, the radiology technologist “got up on her tiptoes because she’s a short lady … and pushed down with force. And at that point, I told her, I got right in her face and I told her, ‘Stop! Get off of him! I’ll do it!”

In the VA investigative report on the incident, the radiology technologist’s name was blacked out.

Cheney testified that the technologist struck him on his hand with her fist. He said he tried to get the radiology technologist’s name. He recalled her replying sarcastically, “What’s my name? What’s my name?”

The nursing assistant reported the radiology technologist’s actions.

A VA investigation said injuries from the abuse included a skin abrasion on Cheney’s leg, broken fingernails and increased pain. The investigation also found the radiation technologist had been accused of verbal abuse previously and had instigated problems with coworkers during the 16 months she had worked at the Dayton VA. Her lack of cooperation with emergency department staff sometimes resulted in delays in patient care since emergency room staff did not want to deal with her, one clinician testified.

The radiation technologist was fired.

Cheney is currently in the Dayton VA for health problems unrelated to the abuse. The VA declined the Dayton Daily News’ request to photograph Jim Cheney in his hospital room in intensive care, despite Linda Cheney’s permission to do so.

Linda Cheney has filed a federal tort claim with the VA as a result of the abuse. The VA could settle the claim, but if it rejects her claim, she could file a lawsuit in federal court.

While Cheney feels the hospital has many good workers, accountability is lacking, she said.

“They have to have respect for the people they’re working for, the people who served their country,” she said.

Contact this reporter at (937) 225-7457 begin_of_the_skype_highlighting (937) 225-7457 end_of_the_skype_highlighting or bsutherly@DaytonDailyNews.com.


VT Editorial Comment: We believed that the VA/OIG had just released the investigation report last Friday, and VT tried to find and post. As of today, the only two VA/OIG reports posted on the IG website concern the suicide of an Iraq War Veteran on Dayton VAMC grounds (2010).

Department of Veterans Affairs Office of Inspector General Healthcare Inspection Suicide After an Emergency Department Visit at the Dayton VA Medical Center, Dayton, Ohio; Rpt #10-02278-26

According to the Executive Summary:

The VA Office of Inspector General Office of Healthcare Inspections received a Congressional request to evaluate the care of a patient who committed suicide on the grounds of the Dayton VA Medical Center (the medical center), in Dayton, Ohio, after leaving the emergency department (ED).

We found that the ED staff made reasonable efforts to provide treatment to the patient in the hours preceding his suicide. In addition, we found that the patient received appropriate and ongoing primary care and mental health (MH) services prior to the event. We also found that providers made appropriate efforts to manage the patient’s pain and treat his MH conditions from August 2008 to April 2010.

However, we found opportunities to improve communication and suicide risk management training. We recommended that the VISN Director ensure that the Medical Center Director [the would have been the same former Dayton VAMC Director Guy Richardson] requires providers to optimize appropriate “hand-off” and intra-staff communication and requires clinical staff to complete Veterans Health Administration’s mandatory suicide risk management training. The VISN and Medical Center Directors concurred with the recommendations and provided acceptable action plans.

AND a 2007 VA/OIG report subject:

Quality of Care Issues at the Dayton VA Medical Center, Dayton, Ohio dated 25 September 2007

According to the Executive Summary for this VA/IG investigation back in 2007, the purpose of the review was to determine the validity of a complaint alleging abuse of Alzheimer’s and dementia patients and alleging substandard living conditions on Nursing Home Care Unit 4 (NHCU4) at the Dayton VA Medical Center.

The VA/IG made three visits to NHCU4, two of which were unannounced.

The VA/OIG did not substantiate allegations of patient abuse on NHCU4. Staff and family members whom they interviewed denied that any abuse occurred on the unit. VA/OIG inspectors did not observe inappropriate care during their visits.

We substantiated that violations of individual patients’ rights occurred and that the environment of care needed improvement.

The VA/OIG did identify problems in staff training in the care of dementia patients. They identified that there was a lack of communication between the executive staff [VT assumes this again means the former Director Guy Richardson’s staff], the NHCU4 Nurse Manager, and unit staff.

The IG also identified problems with the cultural transformation initiative and a lack of management oversight of and appropriate committee membership on the Cultural Transformation Committee.

The IG recommended that management ensure respect for patients’ rights by leaving bedroom doors unlocked, using sedatives within approved protocols, and providing adequate supplies of bulk snacks.

They also recommended that management improve communication between staff on NHCU4 and the executive staff, provide continuous dementia training and education to NHCU4 staff and medical readiness technicians, and adhere to VISN guidelines for implementation of the cultural transformation initiative.

So this is not the first time the VA/OIG has been called to look into patient care concerns at the Dayton VAMC on former Director Guy Richardson’s shift, and it will not be the last time.

We at VT believe that given the attitude of mainstream Veterans groups  desiring to diminish these concerns as simply negative press coverage, unless these Veterans organizations change their defensive attitude toward the VA this will not be the last time the VA/OIG is called to investigate patient care at the Dayton VAMC.

From their website, the Montgomery County Veterans Service Commission is an agency that provides two distinct services:

* Assistance when dealing with the VA (Veterans Administration) including compensation claims and widows’ benefits.

* Emergency financial assistance to eligible veterans and family members who have a demonstrated need.

Despite claims by Mr. Landers that, “If veterans have problems with the Dayton VA, the [Montgomery County] veterans service commission has a statutory obligation to help address the matter.”  In all fairness to the Commission they are not chartered to perform or provide an independent oversight capability. If they did have such a mission and capability, it could conflict with the cooperative relations it has with the Dayton VAMC.

The Montgomery County Veterans Service Commission has eleven members, six appointed by the Montgomery County Commissioners and five appointed by the Montgomery County Common Pleas Court.

The five members appointed by the Common Pleas Court are representatives from: American Legion; Veterans of Foreign Wars; Disabled American Veterans; AMVETS; and either the Military Order of the Purple Heart, the Vietnam Veterans of America, or the Korean War Veterans Association.

VT cautions that (1) these Vet Service Organizations are chartered by the VA to accomplish the services mentioned above so it is not in their vested interest to make the VA look bad, case in point it is not by coincidence that the organizations named above have their logos hanging in the Dayton VAMC, cooperation and coordination with the VA encourages VSOs to come to the defense of the VA, and (2) to their credit they cannot allow Veterans in the Dayton and surrounding areas to lose further confidence in the VA system, especially those Veterans with nowhere else to turn to.

However, the VSOs need to do a much better job in monitoring problem areas given the access to the VA system they possess via an outstanding volunteer programs. Each VSO has eyes and ears within every Veterans Hospital, so instead of downplaying a scandal when it hits, VSOs need to be exposing the scandals.

Now that a new generation of young Veterans are coming into, if not overwhelming the VA system, and our troops and government are STILL AT WAR even if the American people ARE NOT – it is reasonable to expect the Montgomery County Veterans Service Commission to have representatives from younger Veterans Service Organizations welcomed aboard. Iraq and Afghanistan Veterans of America (IAVA), and Veterans of Modern Warfare comes to mind.

It is also questionable WHY Veterans groups and organizations with “AGAINST THE WAR,” or “PEACE” in their logos are not embraced  such as Veterans for Peace, Iraq Veterans Against the War, and March Forward solely based on  discrimination due to these Veteran’s political views or ideology. That is solely based on their views in opposition to the wars.

IAVA, IVAW, and March Forward (among other younger Veterans groups) may not now have the nation-wide membership to fill city or county Veterans Committees per se, but it is only a matter of time before they do.

I do believe that Veterans for Peace has the nation-wide, city, and state-wide membership to be welcomed to any Veterans Commission or panel. I also believe that Veterans groups that question or oppose the wars they served in would make better VA watchdogs than those blessed by the VA (wink).

ROBERT L. HANAFIN, Major, U.S. Air Force-Retired, Veterans Issues Editor, VT News Network


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Readers are more than welcome to use the articles I've posted on Veterans Today, I've had to take a break from VT as Veterans Issues and Peace Activism Editor and staff writer due to personal medical reasons in our military family that take away too much time needed to properly express future stories or respond to readers in a timely manner. My association with VT since its founding in 2004 has been a very rewarding experience for me. Retired from both the Air Force and Civil Service. Went in the regular Army at 17 during Vietnam (1968), stayed in the Army Reserve to complete my eight year commitment in 1976. Served in Air Defense Artillery, and a Mechanized Infantry Division (4MID) at Fort Carson, Co. Used the GI Bill to go to college, worked full time at the VA, and non-scholarship Air Force 2-Year ROTC program for prior service military. Commissioned in the Air Force in 1977. Served as a Military Intelligence Officer from 1977 to 1994. Upon retirement I entered retail drugstore management training with Safeway Drugs Stores in California. Retail Sales Management was not my cup of tea, so I applied my former U.S. Civil Service status with the VA to get my foot in the door at the Justice Department, and later Department of the Navy retiring with disability from the Civil Service in 2000. I've been with Veterans Today since the site originated. I'm now on the Editorial Board. I was also on the Editorial Board of Our Troops News Ladder another progressive leaning Veterans and Military Family news clearing house. I remain married for over 45 years. I am both a Vietnam Era and Gulf War Veteran. I served on Okinawa and Fort Carson, Colorado during Vietnam and in the Office of the Air Force Inspector General at Norton AFB, CA during Desert Storm. I retired from the Air Force in 1994 having worked on the Air Staff and Defense Intelligence Agency at the Pentagon.