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Patients report neglect, mistreatment at Dallas VA hospital

Patient Safety Monitor Alert, February 17, 2005

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Current and former patients at the Dallas Veterans Affairs Hospital reported neglect and overall poor quality of care to The Dallas Morning News.

A Morning News reporter spoke with more than 150 patients, some of whom said their experiences at the hospital were positive. Others reported a long list of patient safety deficiencies, including the following experiences:

• One patient with terminal bone cancer needed turning every two hours. After eight hours of requesting help from the nearby nurse's station, he called the police. Nurses told the police they had checked on the patient several times.
• One patient found his room filthy upon his admission. He discovered that urine-soaked pads had been left underneath his bed and in his nightstand drawer.
• One patient with amyotrophic lateral sclerosis reported receiving one bath in two weeks and that his teeth were never brushed. The patient was too ill to do these things himself.
• One woman tried to visit her grandfather, who had been admitted to the VA with symptoms of a stroke. Upon entering his room, the woman found her grandfather lying dead in his hospital bed. She reported that he had been dead so long that "his ears were blue and his tongue was black. More than half his body was discolored." Nurses told her that they had checked on the man just an hour earlier.

In November 2004, the inspector general for the Department of Veterans Affiars gave the Dallas hospital low marks in areas including management, sanitation, and patient safety.

Changes are being made, said Thomas Stranova, director of the VA Heart of Texas Health Care Network, which operates hospitals and clinics from the Red River to the Rio Grande. "It's like turning around a battleship...We are making visible improvements," he said. "We have a good distance to go yet."

Stranova, who did not blame funding or staffing levels for the problems, said that the hospital need to examine how it uses its resources. "Do we have the right people in the right place?" he said.

Hospital management needs to be more attentive to recently incorporated performance standards, said Stranova. "We're anxious to change the culture."

To read the complete Dallas Morning News article, click here.

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