ATLANTA - Channel 2 Action News has discovered a scathing report on a local veterans hospital that includes patients who committed suicide, died of an overdose and even one who wandered the hallways for eight hours.
The investigation into the Veteran’s Affairs Hospital in Decatur has been underway for months.
Channel 2’s Aaron Diamant working in DeKalb County and Channel 2’s Scott MacFarlane working in Washington obtained a report released by the Department of Veterans Affairs Office of the Inspector General on Thursday.
The report found “policies did not sufficiently address patient care safety,” and “the facility did not have adequate policies or practices for contraband … or clinical changes in a patient’s condition.”
Inspectors also found “there was failure to monitor patients adequately” and “procedures for monitoring escorting patients were not sufficient to ensure patient safety.”
Veteran Tom Wright told Channel 2’s Scott MacFarlane he is not surprised by what inspectors found.
“They are getting kind of pushed aside because they see wounds, but they don’t see wounds here a lot of times,” Wright said while pointing to his head.
In statement, the center's chief of staff, Dr. David Bower agreed with inspectors findings.
"We have already taken very aggressive corrective actions to address each finding. We want to express our heartfelt condolences to the families and friends of the three veterans cited in the reports who died," Bower said.
Investigators also slammed hospital administrators for mismanagement and poor oversight of a major mental health contract.
Hospital leaders said they’re monitoring the corrections so they “never experience these issues again.”
"I think heads have got to roll, of people who are supposed to be knowing what they're doing. They're going to have to be replaced in one way or another," Wright said.
The report included specific instances, including a schizophrenic patient who "got lost" inside the medical center for eight hours.
Investigators said they found "illicit" drug use. Patients not being watched closely and visitors suspected of smuggling drugs inside.
One mental health patient in his 20s with a history of alcohol and drug addiction overdosed on opiates and died, according to the report.
In another case the case the staff lost track of a mental health patient who investigators said "roamed through the building" and "self-injected testosterone."
Internal auditors also said two patients who showed suicidal tendencies weren't monitored as closely as they should've been and killed themselves.
"This report says negligence, mistreatment and purposefulness. This is a very, very sad situation and we owe it to our soldiers to get to the bottom of it and we will," said Congressman David Scott.
Investigators also said mental health patients who were sent out to other facilities for treatment got tangled in red tape. Their audit revealed long waits for treatment in Atlanta.
In one case they say a veteran "called the veterans' crisis line with suicidal ideation due to chronic pain, depression, lack of sleep, and headaches."
Weeks later he was "found unresponsive in a hotel room by police."
Rep. Jeff Miller, chairman of the House Veterans Affairs committee called the report "tragic" and "heartbreaking" and a sign of a "culture of complacency" at the Department of Veterans Affairs.
He sent a statement to MacFarlane that said, "These tragic events are sobering proof that the culture of complacency that exists among some VA managers and employees is truly a matter of life and death.
"The question VA must now answer is ‘where is the accountability?’ It’s time for VA to put its employees on notice that anyone who lets patients fall through the cracks will be held fully responsible. It’s the only way to ensure veterans get the medical care they deserve and prevent heartbreaking events like this from happening in the future,” Miller said.