Journalism in the Public Interest

VA Nurses Scrutinized After Patient Deaths in Two States

A review of records at 29 Department of Veterans Affairs hospitals found that some facilities didn’t keep proper track of their nurses’ skills or competency.



After a patient died last year at a Veterans Affairs hospital in Manhattan, federal inspectors discovered nurses in his unit had a startling gap in their skills: They didn't understand how the monitors tracking vital signs worked.

None of the nurses interviewed could accurately explain what would happen if a patient became disconnected from a cardiac monitor — which allegedly occurred to the patient who died, according to an October 2011 report from the U.S. Department of Veterans Affairs' inspector general.

The incident followed two deaths in the cardiac monitoring unit at a VA hospital in Denver that raised similar questions about nurse competency.

Earlier this month, a broader review by the VA inspector general of 29 VA facilities found only half had adequately documented that their nurses had the needed skills. Some nurses "did not demonstrate competency in one or more required skills," but there was no evidence of retraining, the report said.

An outside nursing expert who reviewed the reports at ProPublica's request called them "troubling" and said the fact that the lapses weren't caught and corrected "signified much broader problems."

The inspector general's findings reveal "a lack of oversight and adherence to accepted clinical and regulatory standards," said Jane Hirsch, a clinical professor emeritus at the University of California, San Francisco School of Nursing, who previously oversaw nursing at U.C. San Francisco Medical Center.

The April 20 IG report also noted that previous inspections had found nurse competency issues in "dialysis, mental health, long-term care, spinal cord injury, endoscopy procedure areas, the operating room and the cardiac catheterization laboratory and with reusable medical equipment."

In a response to the inspector general, the VA pledged to create uniform competency standards for its 152 hospitals and to ensure that evaluations of every nurse's skills are up-to-date. Nurses will not be able to work in areas in which they have not demonstrated competency.

A VA spokeswoman declined further comment.

Nurse competency has increasingly become an issue in medicine. Hospitals and clinics create their own procedures and tests for assessing the skills of nurses, but their adherence to these policies is spotty.

Outside regulators don't test individual nurses, but simply check if a sampling of the nurses' files have the appropriate paperwork certifying competency.

That's what VA's inspector general did for the April review. As such, officials acknowledged that they could not verify whether nurses at those hospitals, or others, are providing competent care.

"We did not look at actual care or actual competence," Julie Watrous, director of the inspector general's combined assessment program, which inspects each VA hospital every three years, told ProPublica.

Only half the 29 facilities included in the new report had complete nurse skill assessment records that met the hospitals' standards, inspectors found. Of the 349 nurses whose files were examined, paperwork showed that 58 lacked skills in at least one area. And for 24 in that group, there was no evidence that anything was done in response.

In an interview, however, the IG official who coordinated the report said she was generally pleased with the findings. Although both the VA and its hospitals had room to improve, she said, all of the hospitals had policies in place and at least some proof of skills in each nurse's file.

"We never found one single site or even person that didn't have at least components of competency assessment and validation," said Carol Torczon, associate director of the St. Petersburg, Fla., office of the inspector general. "Where we found the holes was in the paper process."

Torczon said she believed that the problems identified in Denver and New York were not reflective on the care generally provided by VA nurses in cardiac monitoring units.

Inspectors in the New York and Colorado cases said they could not definitely tie the deaths of the patients to their nurses' care. But they noted that their lack of training put patients at risk.

Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes.

After the patient in New York died, inspectors quizzed nurses and a biomedical engineer about what would happen if a patient got disconnected. "According to some staff, a 'red alarm' would be triggered since a disconnected lead was considered critical," the report said, "whereas other staff told us that a disconnected lead would trigger a yellow alarm or that it would not trigger any alarm at all."

Inspectors also found no evidence that the nurses' competence had been checked. Records showed that one of the patient's nurses had last received training on the monitors 13 years earlier.

Two years earlier at a VA hospital in Denver, inspectors looked into the deaths of two patients on cardiac monitors. After the first death, the hospital gave nurses a basic test of their ability to interpret monitor readings: only one of 28 passed, according to a January 2010 report. The nurse in charge when both patients died had never received specialized training in cardiac monitors.

Even after the second patient died in 2009, inspectors found "it was unclear who was responsible for telemetry training, and staff were not aware that policies had been updated."

Both facilities vowed extensive reforms in responses that were included in the IG reports.

Experts say up-to-date competency evaluations are important because they ensure that nurses, who provide the bulk of the frontline care in hospitals, have the skills for their position.

"It would appear that the old adage 'inspect what you expect' has most certainly not been taken very seriously in these environments," said Hirsch, who was chief nursing officer at UCSF Medical Center for nine years.

After reading the New York and Denver reports, Hirsch said her concern wasn't the incidents themselves as much as that the competency of the nurses hadn't been documented or evaluated in a long time.

Had she been in charge, the findings would have caused her "to be really nervous and want to jump on it immediately," she said.

April 30, 2012, 4:41 p.m.

I thought I was beyond shocked at the criminal treatment meted out to our veterans.  There has been story after story about veterans ruined for life, if not actually killed, by neglect, incompetence and bureaucracy.

Can you imagine a reaction like this:  “We did not look at actual care or actual competence,”  Tell that to the families of the dead veterans. They fought for their country; their country didn’t fight for THEIR lives!

Can you believe the IG’s report: “In an interview, however, the IG official who coordinated the report said she was generally pleased with the findings. Although both the VA and its hospitals had room to improve, she said, all of the hospitals had policies in place and at least some proof of skills in each nurse’s file.”

Oh, goody-goody!!!  So “policies in place” and “proof of skills” will bring back the murdered veterans!!!

Of course no one will be punished for their deaths.  And our corrupt government will keep on shoveling money out to Wall Street and Big Pharma, while stinting on the care of our veterans!!!

The Denver VA is just as guilty. They had to shut down their operating rooms due to an unknown “substance” on surgical instruments. A local employee ratted on them to the news. This is the same VA that won’t allow MD’s to change allergy/adverse reactions in the patient’s chart, the pharmacist who “knows all about me and told a UCH MD’s nurse not to use my name in an email” and denied a medication to me that I’ve used for the past 8 years but the VA wants me to use their generic substitute cefpoxidime for Omnicef (cefdinar) and wants a Pre auth, meaning I have to use that junk first and if it doesn’t work, then I may get the other generic I know works for me without adverse reactions. This pharmacist also wrote in my VA record to an MD how to treat a condition “on my legs” when the condition exists on my R flank and has been there since 2008. She knows NOTHING about me and should not be telling MD’s how to treat me without even seeing me and SHE IS NOT MY doctor. I’ve told her so on the phone. The VA director, Lynette Roth, if that’s how you spell her name, because she didn’t bother to spell my name correctly in her response to me that she considered “closed”. I replied it’s not closed and it’s going up the chain. I also told them many of them need to be replaced as they are obstacles to patient/veteran care and to the physicians. The second letter was signed by another RN for the director. They consider themselves to be respectful towards veterans for our service. They have a high turnover and contracted MD’s and the Univ of Colorado interns/residents fill in when they want some time off of their usual routine to see how badly you don’t want to work at the Denver VA but can still exploit and abuse patients.

betcha the nurses were male

(A much longer and more heart-felt comment just vanished. Maybe it’s for the best.)

The sad truth is that Nursing Education is 100% misguided right now. And this has real consequences because who teaches MDs how to code a patient (during their MICU rotation)? NURSES. Ironically, the tragedy of nursing education is based on an effort to make nursing ‘seem’ more like a ‘real profession.’ I do not have all of the answers to turning this train around, but I have some ideas for starting points. First, if you want a BSN as a requirement, go for it. Unfortunately, it’s not going to change a thing. What matters is that smart people choose nursing, which is happening less and less, due to the opportunities that women now have and for which WE HAD TO FIGHT. We must be prepared to FIGHT AGAIN. We need nothing less than a total education overhaul. We need an ad campaign to attract the best and the brightest. It goes without saying that we need more pay. I should not have to work over an hour to pay my cleaning lady for her hour’s worth of work—nobody dies if she has a bad day. With a better education, higher pay (and status), and the ability to take it personally—not to mention taking full responsibility—when something does go wrong. Nursing is cool. The docs can take the credit. We’re having all the fun!

Wonder how many of the above good people will take the time to sit down and compose a STRONG email and/or letter to their (hah!) elected representatives, the White House, and your local newspaper as well as the national newspapers like the NY Times, Wash Post and LA Times.

And make indignant phone calls to the same.  Yes, it takes time, but if you don’t do it, who will?

It may be cathartic for us to bitch to each other, but a gigantic machine like nursing ed and supervision won’t move unless we supply the grease.

Hypatia, no matter how many letters are written and sent it won’t make any difference. A shift in nursing education requires a total shift in culture. And we still have an historical hangover about nursing being “women’s work” and therefore undervalued, underpaid, and under-appreciated.

Clearly, Charles O. doesn’t understand SHIT about nursing (you like my all-caps?) and he does not have any clue what it means IRL when you give a nurse too many patients or patients that are too sick for his/her level of training and experience. Unlike Ornstein, I know that nurses are not stupid. When hospitals cut budgets, who do you think goes first? That is the real threat to patient safety, not nurses who are trying to do too much with too little and pushed to do it faster. That’s when mistakes happen.  There is also (and this is the legitimate part of his essay) the great disaster called nursing education. Let’s start by having hospitals put nurses in the “assets” column and not the “expenses” column and educate nurses as if they have the most important job in the hospital, which they do. Why pick on nurses here? You’re much better off with an OK MD and an excellent RN than with an excellent MD and an OK RN. Remember that next time you are in the hospital.

Having been a nurse since 1995, I can tell you that I am not surprised that this specific issue is of concern. Staff nurses have to demonstrate competency in MANY specific skills on an annual basis. Continual education and competency certification for each and every nurse must be carried out by a group of nurses whose roles have been cut: Clinical Nurse Educators and Clinical Nurse Specialists. I watched as these positions were eliminated in the 1990’s, and unfortunately have not been brought back in many places, or not brought back in enough numbers. Nurse managers already have responsibility for staffing, budget, discipline, and in most places even the payroll process. Yet in many hospitals, the managers are also expected to provide education and clinical oversight. It is absurd! We need nurses with Clinical Expertise back in the hospitals.I know the VA has supported the new Clinical Nurse Leader role, which has potential to solve some of these problems - but have they been placed on most units? No. And their primary focus is on care coordination, NOT the professional development and competency of staff.

An additional concern - when education is provided to nurses, it is squeezed into a 5 minute inservice in the middle of a nurse’s shift when they are responsible for patient care. And time budgeted for professional development is considered “non-productive time.” There are very few hospitals in this country allowing a sufficient amount of this time to be provided to staff nurses. They are being squeezed for every second of direct patient care that they can provide. And we wonder why burnout and competency deficiencies are such a problem?

The budget that supports nurse education and professional development in terms of the staff required (Clinical Nurse Educators and Clinical Nurse Specialists) and the time (“non-productive time”) needs to be seen as an INVESTMENT in patient safety, not a COST that should be minimized.

I agree, too much responsibility is being given to managers. I’m all about saving the almighty dollar but when the difference between life and death falls upon the proper organization, placement, and training of the staff, there needs to be a job primarily for that purpose. However, it is absolutely mind blowing to me how a nurse can even be hired without knowing how to read vital signs from a monitor. I do not know much about the medical field and I realize not all nurses can work on the same level, but should it at least be a requirement to understand a how to do that?

I agree, too much responsibility is being given to managers. I’m all about saving the almighty dollar but when the difference beween life and death falls upon the proper organization, placement, and training of the staff, there needs to be a job primarily for that purpose. It is absolutely mind blowing to me how a nurse can even be hired without understanding how to read vital signs from a monitor. I realize that not all nurses are on the same skill levels, but should’t that at least be a requirement?

It’s simply not true that a licensed RN cannot read/interpret vital signs. Nurses are always an easy target.

The article and comments, I think, are all well on-target.  We’re not treating our patients (or veterans) well, and the overloaded nurses (because we’d never overload a doctor) are going to miss things and be unable to deal with basic skills.  Anybody who’s had to work extended hours knows you don’t get better with age in that situation.

However, one thing I do want to point out that’s hopefully helpful to somebody is that, when there’s a problem with people interpreting the data in front of them, there are three solutions.

1.  Get better people.  It’s the route that we instinctively want, generally, but in most cases, your better people will decline unless you also get more of them.

2.  Re-train the people.  This is fine, but doesn’t solve the overload problem.

3.  Fix the data.  From what I see of hospital equipment, it’s more expensive and has better displays on them, but they use the high-end graphics to show exactly the same data the cheaper ones did thirty years ago.  If the problem is that a nurse can’t figure out if the machine is plugged in, what idiot is selling a device in this day and age that doesn’t brightly display “THIS MACHINE IS UNPLUGGED”?

I don’t mean to trivialize the problems, here, but making the data more presentable is low-hanging fruit.  If anybody has contacts with medical suppliers, please pass it along, if you think it’s helpful.

@Hypatia - I agree with you in calling, writing and taking some active stance.  It does take much more than a comment on a blog. 

The article starts out speaking of the nurses understanding and skill level.  Why is that not the responsibility of the supervisors and managers just as it would be in any other position where you are expected to know what you’re doing.  Even more so in this situation where you are responsible for a life. 

Our society is becoming less and less responsible and accountable each day.  In this reactionary society, it takes death to catch our attention and that’s only for a brief moment. 

Unless we raise the bar in this country our veterans will die from ignorance, lack of caring, no supervision, poor supervision, bad management.

This article is a sad testimony to how dumbed down our entire society is becoming.  It’s not just VA Nurses, we just haven’t heard about how badly it is. 

So yes, you are right.  We should be outraged, angry and demanding the very best care for our Veterans and ourselves.  Phone calls, emails, complaining, contacting the media; all those actions you suggested work, they work.

It is worse than all these comments. And it is not limited to VA’s.
Also, many kind Immigrant Nurses, but unfortunately, most do NOT have a clue as to the Latin or mathematical written Prescriptions to give a patient. SO you never know what you may get or how much or how little. Hospitals are dangerous places today world. And many do NOt change/clean the breathing hoses or ventilators hoses daily as they should be. These moist hoses are breeding grounds for every kind of bacteria, virus and worse if not changed daily. 

JUST hope that anyone in a hospital today, has a friend or a Loved one that can be there daily for them to Know what they are taking etc. and to watch out for them. Always ask the doctor What Meds they should be getting, how to get them and how much and when. God watch over those that cannot do this and most our Vets cannot.

Hospitals HAVE to be responsible. They Assume that if you went to Nursing School or If you went to Med School, that you know all you should know.  That is far far from the truth. And Specialties are just that, onggoing education should be a requirement for salary & job.

I have worked at a VA hospital for more than 15years. One thing I know for sure is if you don’t know how to do your job, the union will force management to move problem nurses around and round. It is hard to fire a bad nurse, it can be done but with the VA UNION is very hard to do. The unions also protect good nurses and do good for all employees. I can’t tell you how many times I have worked with nurses that need not be anywhere around a human life. Also, nurse educators should be educators that know about nursing and not necessarily nurses. They should be specifically hired to train nurses in their skills. I see a lot of unprofessional behavior more at Va facilities than at outside hospitals; i.e.; housekeeping arguing in the hall, cell phones all over the place, nurses talking very loud, almost all personal wear many different scrubs, and the jewelry and piercings and long nails are in need of improvement. So maybe a little improvement would be a big help. But overall many lives are saved and a better quality of life is given to our veterans.

My husband had a service connected back surgery in october 2011.  he was released from the hospital the next day.  he already had active prescriptions for valium,tramadol,neurotin (for nerve damage),zoloft,sleeping pills,hydrocodiene and the va doctor prescribed oxy on top of all that.  What do you think happened to him. he died. three days later.  what is going on with these doctors. and the doctor had the nerve to tell my husband that he could take all of the meds it wouldnt hurt him.  he was like a walking zombie… This has to stop!!!
frustrated Arkansas Gulf War Widow

Jay Thompson

May 4, 2012, 4:23 p.m.

This is not my experience with NURSES IN THE VA system! They
are great at the VA outpatient clinic in Knoxville, Tn., Mountain Home, Tn., and of course, Vanderbilt VA hosital in Nashville, Tn.!

I was in a VA hospital recovering from a partial vital organ removal.  The Surgean was wonderful, and I owe him so much, in my opinion, he was the 2nd opinion of another Doc, who was going to fillet me good.  This Doc did a laproscopic in something I heard was impossible. 

I was put in the hospital room without iv for almost 2 hours without pain meds, and everthing wore off.  I was in agony, and the nurse said, “we can’t do nothing without paperwork.”  Apparaently, someone dropped the ball, and if it wasn’t for my wife raising caine, I would have laid there longer.  It was horrible!  One nurse bumped a button on the bed, and bent me backward stretching all me stitchses and I was screaming in pain asking her to push the other button.  She said she didn’t know how and left me.  Some would handle my room mates urine bottle, and come back to adjust me or touch stuff without gloves or washing hands!  It was a freeking nightmare.  They withheld pain meds, stating, “I don’t see them on the chart” and I’d call my wife with my cell phone and she had to call someone else, and then I’d get my pain meds.  Vindictive little tyrants some of them nurses. 

A bit more than 1/2 of them were wonderful!  I got out of their as soon as I could, but I still thank the VA for my meds, I just wish they would jerk the slack out of the Jerk nurses, get rid of the dead weight!  Jobs are rare and if people can’t perform then replace them!  It isn’t fair to honor tenure over patient care!

Lazy is a disease that can be corrected by people motivated by debt who need a job, and who know they will be fired if they are slackers!

Vindictive nurses should have to work in the morgue!

May 15, 2012, 2:52 p.m.

Google the case of David A. Shaller M.D. who is triply-boarded.  He warned the doctor-administrator at the Wilkes-Barre, Pennsylvania VA hospital about the risk of placing ventilator patients on a ward where nurses had not been trained in their use.  Two patients died.  Dr. Shaller lost his job.

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Nurse competency or the much more common problem understaffing and overworking nurses?

Mary Caulfield

May 15, 2012, 4:22 p.m.

I became a nurse after the VA at 23rd St. allowed my life partner to aspirate and develop ARDS in their SICU unit in 2003. After 3 months of rehab they sent him out to St. Albans to recover “at his own pace.” He was dead in two and a half weeks. The people there had no idea whatsoever how to care for him.

I know now what I didn’t know then—the VA is underfunded and their nurses are overworked. When that happens, people die. Don’t blame the nurses, blame the bean counters.

Anne Marie Martinez

May 15, 2012, 5:20 p.m.

Why am I not surprised?  The way this country treats our vets is disgraceful, and inhumane.  This country uses our troops til they are used up.  Then they just toss them off like they are no longer any use.  Well, vets are of great use to all of us…we are mothers, fathers, sons, daughters, cousins, brothers, sisters, and very brave and courageous.

Not one other American say that about themselves unless they are a VET..

Nursing shortages with increased responsibility and nursing aid staff, i.e., one registered nurse for 30 or more patients with certified nursing staff is just to dang much to put on acute care and critical care units.  Saving money so that the Administrators can have fat benefits packages is criminal.  In nursing home settings the registered nurses aren’t supposed to check on patients only if the CNA is bright enough to bring the necessary information to the nurse.  No hands on care and no eyes on care.
Yes, and the hospital infections gone to run rampant because hospitals are too dang cheap to have nasal swabs testing done on all staff who have patient contact to get carriers away from vulnerable patients, and get treatment for the carriers.  Is it any wonder without this fairly inexpensive test per staff that MERSA is running rampant.
Back to expecting nurses to be all knowing and competent staff, my father died in a VA hospital after two heart attacks, family never notified. The staff on the medical floor transferred him to CCU, and the staff on CCU and the general medical floor thought the other contacted the family. My father died alone two days later never knowing why his family did not come to his side.  Such a loss cannot be recovered but I imagine the same problems existed then too. Too many responsibilities on both staff.  It has never been perfect.  Yet no one is clamoring for a lower nurse to patient ratio.  It just gets worse.
Glad I am now retired, at age 69.


May 16, 2012, 3:19 a.m.




I don’t blame “the nurses,” I blame the nurses who take their job for granted, are incompetent, are on power trips, or whatever, and fudge their responsibilities. 

When I was in the Hospital for a partial organ removal, I met some great nurses who had my back!  Then there were those, who I asked to wash their hands after handling my room mates urin bottle before they started touching my stuff.  I had to do that a few times.  One CNA said, “don’t worry about mersa, my daughter has it, it isn’t nothing.”  I was shocked!  But the ones I would ask to do their job correctly, retaliated by ignoring my calls or lost my pain meds or couldn’t find them in the computer, till I would call my wife, and she would get them straightened out!

The Doctors were marvelous and fair, but there are Nurses who are lazy and immature, and cannot remain neutral when patients who are in major pain, and may offend the nurses, if you say the wrong thing wacked out on morphine.  Human Nature is a tough one.  I just encourage nurses to be disciplined and happy about their job.  If they are not happy leave!

donna pearson

May 16, 2012, 11:18 a.m.

This could and does happen at any hospital. When people use the agency nurses this happens. With the government run hospitals such as the VA they have a responsibility to report any and all untoward incidents to the public or family etc. At private hospitals you would be appauld to see how much cover up there is to protect all and any untoward incidences. I have worked at both to know. Cover up happens at private hospitals reporting happens at the VA hospitals.

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