Marsha Austin and Karen Augé, Denver Post
Denver's veterans hospital is a crumbling, filthy mess that compromises patient privacy and jeopardizes the health and safety of patients and staff, a federal inspection has found.
In fact, infection control at the hospital is so poor that patients with compromised immune systems couldn't be admitted for long periods in the last two years, and patients and staff alike told inspectors they don't believe the hospital is clean.
The report, released Monday by the Office of the Inspector General of the federal Department of Veterans Affairs, found that the aging hospital at 1055 Clermont St. in east Denver met federal standards in only four of 16 areas surveyed. In the remaining 12, the report catalogued a sometimes stomach-turning list of deficiencies and shortcomings.
Those findings include:
- Dirty strips of gauze - some with what appeared to be dried body fluids on them - were attached to light switches over patient beds for use as pull cords in the surgical intensive care unit. Employees reported the strips weren't changed between patients.
- Feces and blood on the toilet and shower floor in a patient room.
- Ongoing pulmonary infections forced the hospital to stop admitting immune-compromised patients, such as those who had undergone organ or bone marrow transplants, on two separate occasions in 2002 and 2004. In one of the cases, such patients had to be sent to other hospitals for more than a year.
- Multiple holes in a post-operative care unit.
- Paint and drywall chipping off walls in operating rooms, including chipped drywall where surgical instruments are stored.
- Dirty linens lying on the floor in the surgical intensive care unit, and dirty linen carts being used to deliver clean linens.
- Staff's food and dirty linens stored in the same break room, the door to which was propped open by a tube attached to the bedpan washer.
- An open vent between a dirty utility room and a room where biopsies are performed.
- A chemotherapy clinic so small that patients sat arm-to- arm, "resulting in patient privacy, infection control and safety deficiencies."
- Stains and "foul odors" in bathrooms throughout the hospital.
- Hospital officials say that as of the end of October, the key deficiencies had been addressed.
The problems stem mainly from an aging building that is in constant need of repair, said Susan Broschat, spokeswoman for the Eastern Colorado VA Health Care System.
System director Ed Thorsland was unavailable Tuesday for comment.
"Remember that this facility is 53 years old, so lots of things we have trouble with," Broschat said.
Hospital officials and some of Colorado's congressional delegation are pushing to move the medical center to the University of Colorado's new Fitzsimons campus.
While funds have been allocated for planning, the move has not been officially approved.
Since federal inspectors uncovered more than a dozen major safety and sanitation violations at Denver's VA Medical Center, hospital administrators have "taken numerous steps" to improve conditions at the 128-bed hospital, Broschat said.
"We have very high quality patient satisfaction scores," she said. "Our patients really do love coming here."
Navy Cmdr. Len Deemer of Aurora recalled lying in bed during a recent stay at the medical center and inhaling the stench of human feces. The patient in the next bed was incontinent and required frequent cleaning, said Deemer.
But VA nurses "dumped the excrement in a container" between the beds and left it there, he said.
"The people really seem like they don't want to be there," Deemer said of the staff.
State Treasurer Mike Coffman called the findings "a tragedy." But, said Coffman, an advocate on behalf of fellow veterans, it follows a pattern of the nation's not caring for its veterans.
"Unfortunately, it's something that has happened in this country before, where people are excited and supportive when young men and women go off to war, but when they come back and have needs because of their injuries, they seem to be forgotten," he said.
While VA hospitals in surrounding states have had their problems with cleanliness and safety, violations have been nowhere near the size and scope of those identified at Denver's VA medical center, said Lawrence Brio, director of the VA Rocky Mountain Network, a nine-state region that includes Colorado.
"It's not our standard," said Brio, who became the network's director in October 2003. "It's a place that needs more work."
However, the Denver VA did rank first in the nation in 2004 for quality of patient care among VA medical centers, he added.
Now VA officials are working to take care of the facility itself, Brio said.
"We've done our homework," he said. "And we're pretty close to what we have to fix."
By August, Brio and Thorsland had taken "aggressive action" to correct federal inspectors' long list of violations, according to the OIG report.
"The administration here in Eastern Colorado was working to correct these things; they just weren't working fast enough," said Brio.
In a memo to the OIG dated Oct. 25, Brio said "the facility has addressed all identified deficiencies and is continuing to improve and resolve" the problems.
By November, the hospital had set up a system for staff to report unclean and unsafe practices and had begun to scrutinize patient complaints, Thorsland said in a separate memo submitted Oct. 15.
By March 31, 2005, the Denver VA medical center will repair all damaged walls and ceilings, replace patient light pull cords, repair leaks, clean restrooms and establish safe procedures for handling linens, among other things, Thorsland said. The center also plans to seal a dirt floor in the basement.
Patients at risk of infections from mold spores continue to be sent to other hospitals.
The hospital isn't the first Colorado veterans facility to face scathing criticism this year.
Inspectors found "major problems" at the new State Veterans Nursing Home at Fitzsimons, and as a result, the Department of Veterans Affairs withheld certification of the home. The state has hired an outside firm to clean up the widespread problems at the home.
Last week, Thorsland told The Denver Post that budget shortfalls had left the center understaffed and unable to meet growing patient demand.
But the system fared better than most VA hospitals nationwide, Brio said.
The VA Rocky Mountain Region ranks in the top 30 percent of VA health care regions in 2005 funding, he said.
"There will never be enough money," Brio said.
Review of the VA Eastern Colorado Health Care System
Click to open the report
(PDF File: NEEDS ADOBE ACROBAT READER)
( '? note: My father died in this hospital in 1979. Things were just as bad, or worse, at that time...
end ( '? note