From Military.com:
“VA Cuts Off Assisted Living Home
After Finding Veteran Dead for 4 Days”
Federal officials pulled veterans
from a Van Nuys assisted living home after finding that the facility had
reported a social worker visiting a veteran who had been dead for four days,
according to a report released Thursday. The investigation by the U.S.
Department of Veterans Affairs also found serious medication errors at the
California Villa home. A 100- year- old veteran with sepsis was denied
prescribed antibiotics because they were "not covered by Medicare "
and ended up hospitalized a second time, the report said. Another veteran
received a double dose of medication and a third was denied prescription drugs
and charged $5 a meal because he preferred eating in his room rather than the
cafeteria. Authorities from Washington, D.C., blamed the VA 's Greater Los
Angeles Healthcare System for failing to investigate and address "serious
residential care concerns " at the facility, but added that program
administrators had not reported the problems to upper management. The
healthcare system had California Villa on an approved list, and helped place
veterans there, but suspended referrals and relocated most of their clients
during the investigation in 2018. The investigation was initiated by the U.S.
Special Counsel based on whistleblower complaints. "I am shocked that such
lax oversight of facilities providing critical care for vulnerable veterans
ever occurred, " Special Counsel Henry J. Kerner said in a letter Thursday
to the White House. The investigation findings were also relayed to
congressional oversight committees. The California Department of Social
Services had sought to revoke California Villa's license after finding that the
facility in 2017 had not addressed serious safety issues stemming from a
resident 's repeated assaults on other residents, which resulted in at least
one hospitalization, state records show. The state agency also found that staff
did not adequately clean feces from the furniture. A new license for the
facility was issued in March under the name California Green Tree Villa Ast Lvg
& Memory Care. It is licensed for 200 residents. Administrator Jacqueline
Beltran said the facility changed hands Aug. 1, and added that she would relay
questions to the new owners, who did not respond. Kerner, in his letter, said
VA investigators found California Villa facilities in "disrepair" and
its medicine room disorganized. The false report of the visit to a dead veteran
stemmed from a misidentification by California Villa staff, investigators said.
The veteran was living on a locked ward for residents with Alzheimer's disease
or dementia, or who were at risk of wandering. When a case worker arrived for a
visit, California Villa staff directed her to the wrong resident, the
investigation found. After the mix- up was discovered, an addendum was added to
the veteran's case notes saying "Please delete, wrong veteran." Investigators
said the confusion called into question whether other residents had received
incorrect medication. The VA investigators did not uphold a whistleblower
complaint that a VA manager had improper relationships with patients. Werner
praised the whistleblowers for bringing the problems to light and said one of
them hoped the VA would investigate further allegations of a bedbug infestation
and other problems.
^ This is wrong on so many levels.
The VA is at fault. The State of California is at fault. The assisted-living facility
is at fault. And the employees at the assisted-living facility is at fault. Because
of the incompetence of so many people innocent elderly veterans were abused and
even died. How many veterans have to be abused before something concrete and
real is done around the country at every level? How many veterans have to die
before something concrete and real is done around the country at every level? I
can only hope that the men and women who either committed the abuse themselves
or knew about the abuse (or should have known about the abuse) and did nothing
about it will be fired and sent to jail. I also hope that when those same men
and women are elderly and need care themselves that they are given the same
kind of treatment that they provided to these elderly veterans. ^
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