Officials at the Brockton Veterans Affairs Medical Center nursing home, rated among the worst VA facilities in the country, knew this spring that they were under scrutiny and that federal investigators were coming to visit, looking for signs of patient neglect.
Still, when investigators arrived, they didn’t have to look far: They found a nurse and a nurse’s aide fast asleep during their shifts. One dozed in a darkened room, the other was wrapped in a blanket in the locked cafeteria.
The sleeping staffers became a key focus of a scathing new internal report about patient care at the facility, sparked by a nurse’s complaint, according to a letter sent late last month to President Trump and Congress by the agency that protects government whistle-blowers.
Investigators with the VA’s Office of Medical Inspector largely substantiated the whistle-blower’s complaints in September, concluding that a “a substantial and specific danger to public health and safety exists” in the 112-bed facility.
“We have significant concern about the blatant disregard for veteran safety by the registered nurses and certified nurse assistants,” agency investigators wrote in a report.
The problems at the Brockton nursing home are the latest to surface in a review of VA nursing home care by the Globe and USA Today.
The Brockton VA nursing home is a one-star facility, the lowest rating in the agency’s own quality ranking system of its 133 nursing homes. Forty-five nursing homes received one star in the most recent ratings, including two other VA nursing homes in New England — Bedford, Mass., and Augusta, Maine.
In June, the Globe and USA Today revealed the VA’s own secret ratings showed these facilities and more than 100 other VA nursing homes scored worse than private nursing home averages on a majority of key quality indicators last year.
VA spokeswoman Pallas Wahl said officials took “immediate corrective action” in the wake of the internal investigation. The two sleeping nurses no longer work at the Brockton nursing home.
The facility’s one-star rating, she added, is undeserved and is not an “accurate reflection of the quality of care delivered to our patients.” The investigators “did not find evidence of veteran harm or neglect,” Wahl said.
The Brockton whistle-blower, licensed practical nurse Patricia Labossiere, complained to a federal whistle-blower agency, the Office of Special Counsel, earlier this year, after her repeated complaints to supervisors were ignored, she said.
“I am a no-nonsense nurse who took a vow to take care of patients,” Labossiere, who quit in July, told the Globe. “We are there to be kind and treat others as we would want to be treated. I could not believe that this was how we treat the people that fought for our country.”
Labossiere said she saw instance after instance of poor patient care at the facility within days of starting to work there last December. She told the federal whistle-blower agency that nurses and aides were not emptying the bedside urinals of frail veterans. Nurses failed to provide clean water at night and didn’t check on the veterans regularly, as required, she said. And they often slept when they were supposed to be working.
She offered some specific examples: One patient was having trouble breathing because his oxygen tank was empty. Another fell — his feeding tube got disconnected and the liquid splashed onto the floor — and didn’t appear to have been monitored by staffers for hours.
The VA investigators did not substantiate those specific allegations, saying the patient with the empty oxygen tank suffered no ill effects. Investigators couldn’t confirm that the patient who fell had been neglected because the records had been shredded “in accordance with the local policy.”
The Office of Special Counsel ordered the VA’s Office of Medical Inspector to investigate Brockton following Labossiere’s complaint earlier this year. The office turned over its report in September to Special Counsel Henry J. Kerner, who sent the findings to Trump and Congress on Oct. 23.
“Because a brave whistleblower came forward, VA investigators were able to substantiate that patients at the Brockton [nursing home] were routinely receiving substandard care,” Kerner told the Globe in an e-mailed statement.
“While appropriate actions were recommended to improve care, I remain concerned that the whistleblower felt the need to resign from her position citing a retaliatory culture. Personnel who try to improve patient care at VA facilities should never experience retaliation.”
According to the VA’s own data, Brockton residents were, on average, more likely than residents of other VA nursing homes to deteriorate, feel serious pain, and suffer from bedsores, according to agency data. They were nearly three times as likely to have bedsores than residents of private nursing homes.
Attorney Andrea Amodeo-Vickery, who has represented medical professionals who filed complaints about the VA facility in Manchester, N.H., said the Brockton report shows how difficult it is for whistle-blowers to have their complaints taken seriously.
“This report illustrates just what it takes for this VA agency to find wrongdoing by its own agency — they must catch the culprits red-handed,” she said. “As I have experienced in my representation of many whistle-blower physicians and physician assistants, the Office of Medical Inspector does not give their testimony credibility unless they find a smoking gun that is impossible to ignore.”
Massachusetts’ two senators reacted swiftly Wednesday shortly after the Globe and USA Today story was published online.
“These latest revelations are completely unacceptable and betray the promise we make to care for our veterans,” said Senator Edward J. Markey.
Senator Elizabeth Warren called the latest report “part of a troubling pattern of misconduct at VA facilities in Massachusetts and underscores the need for rigorous oversight of their performance.”
Leaders of the country’s two largest veterans organizations called on the VA to make public inspection reports detailing care at the VA’s nursing homes.
“While much of the media’s attention has been on the proper implementation of VA healthcare legislation, we cannot forget about 46,000 mostly senior veterans who reside in these nursing homes,” said B.J. Lawrence, commander of the Veterans of Foreign Wars of the US, and American Legion national commander Brett Reistad in a joint statement.
This is not the first time the Brockton VA has come under fire by the Office of Medical Inspector.
In 2014, a doctor at the nursing home alleged that three veterans with significant mental health issues received “inappropriate medical and mental health care.”
Investigators largely substantiated the allegations, finding that two veterans with significant psychiatric issues did not receive adequate treatment for years. They did not substantiate the allegation that the third received improper medication.