Designated ‘Fixer’ for Troubled VA Hospital Missed The Signs For Years


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Luke Rosiak Investigative Reporter
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Victoria Brahm, the executive assigned by the Department of Veterans Affairs to fix its troubled Tomah, Wisconsin, hospital, once “astounded” a colleague by discarding credible complaints of wrongdoing at the facility, well before abuse of veterans exploded into a national scandal.

In a newly-released sworn deposition, the regional office’s deputy director, Renee Oshinski, said that before the scandal broke, Brahm — then the regional VA office’s nurse executive — had been given a mountain of evidence of opiate abuse at Tomah, and somehow concluded that there was no truth to any of it.

“I was astounded that they were all unsubstantiated,” Oshinski told investigators from the Senate Committee on Homeland Security and Governmental Affairs. “With the number of things here, I would have thought there would have been some partially substantiated or whatever. I mean, just based on the number, that it’s not a normal response that we would have.”

The Tomah hospital has been called “Candy Land” because its chief of staff, David Houlihan, gave out painkillers at wildly atypical rates in an apparent attempt to sedate veterans rather than treat their underlying conditions. They were referred to as “zombies,” and some died of an overdose while in the hospital’s care.

The deposition says that the department’s much-criticized Inspector General got detailed tips about these problems and instead of investigating them itself handed them over to the regional office above Tomah. At the regional office, the person in charge of investigating was Brahm, then the regional office’s nurse executive.

But like the IG, the regional office did nothing to act on the information. Whistleblowers who tired of meeting dead ends inside the government later took their concerns to the media, which exposed problems, which Senate investigators and others confirmed.

Officials at VA have since admitted serious deficiencies and instituted a “100-day plan” to turn the hospital around. The state of Wisconsin temporarily took away Houlihan’s medical license, he was removed from the government payroll, and the hospital director was forced out. Brahm was named acting director of Tomah.

“An ongoing look at Dr. Houlihan’s prescribing practices” was “something that Vicki Brahm and Donna Leslie were involved in” as part of their duties in the regional office, Oshinski said.

Senate investigators pointed to, as an example, “a number of allegations regarding patient care and opioid prescription … going into specifics” from an employee at Tomah. “The IG declined to investigate these allegations and instead referred it” to the regional office. A document from that office concluded that there was nothing to them.

Oshinski said that “Vicki Brahm I think had the primary responsibility for this document.”

Oshinski was critical of the IG for outsourcing investigations to the same entity being investigated instead of conducting an independent probe. “I’m surprised they didn’t do this,” she said.

“The IG is not investigating and they are determining, they are giving it to us to look at and then they look at our response and they either clear the response or say this is going to be closed, they send it back to us and say we need more work … or the third would be they decide to do some review on their own.”

The VA’s acting inspector general resigned under pressure from veterans and Congress after defying a subpoena for documents related to Tomah issued by Sen. Ron Johnson, a Wisconsin senator who chairs the governmental affairs committee.

Brahm, on the other hand, was promoted. Oshinski said Houlihan had a close relationship with Brahm. “Dr. Houlihan would choose to call Dr. Murawsky [the regional office’s director] or Vicki Brahm,” she said.

Brahm and others in the regional office should have seen the basic conflict of interest in the fact that Houlihan was both Tomah’s chief medical officer and its only psychiatric prescriber, meaning complaints about his prescriptions might be handled by him.

“Being a provider as well as the chief of staff is something that we are now aware is not optimal,” she said.

Indeed, he was privy to some of the inquiries into his prescribing. “There would be no firewall. He would, he would have been aware of everything that was being sent up,” she added.

Tomah was the only hospital not to have a policy about what to do when patients asked for early refills of painkillers, claiming they had lost their pills, she said–something the regional office knew about for years but didn’t correct.

Oshinksi also said that from her perspective the employees union did not appear to be especially proactive in putting a stop to practices that harmed veterans, noting that only one union representative was in contact with her, and only then by sending occasional text messages.

Since taking over as acting director, Brahm has seemed to continue to cover up problems. When Houlihan appealed his firing — asking to be returned to his job as top doctor even though he no longer had a medical license — Brahm heard his pleas for an entire week, and instructed the entire hospital staff to call police on any news reporters that entered the hospital, in an effort to prevent coverage of the fact that he could be restored to his former job.

And Tomah’s 100-day plan consists largely of monetary and lifestyle benefits to employees instead of reformed practices to help veterans, who are barely mentioned. Under the heading “restoring trust,” the bulk of the plan is devoted to doing more “union partnering,” giving employees more “praise” and creating a “diversity committee” and an Employee Wellness Center.

The VA has frequently shuffled failed executives between positions, giving the illusion of management shakeups, because civil service rules prevent it from firing them.

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