Robert Kneschke/

VA Review Finds Culture of Fear Among Staff in ‘Candy Land’

Initial findings of investigation show Wisconsin facility overprescribed pain pills to vets.

A Veterans Affairs facility in Wisconsin overprescribed pain pills to vets and bred a culture of fear among staff that compromised patient safety, according to initial findings in a department investigation.

The VA’s internal investigation, which Secretary Bob McDonald directed the interim undersecretary of health to begin in January, found “unsafe clinical practices” at the Tomah facility in pain management and psychiatric care. For example, in six of the 18 cases the department reviewed, high doses of opioids and depressants contributed to patient injuries, while 12 out of the 18 cases “demonstrated extensive use of opioids and benzodiazepines.”

The review team also found that “an apparent culture of fear at the facility compromised patient care and impacted staff satisfaction and morale,” according to the preliminary findings outlined in a March 10 memo to McDonald from Interim Undersecretary for Health Dr. Carolyn Clancy. The department is conducting a more in-depth investigation of the clinical and administrative practices at the Tomah facility.

Patients at the VA medical center in Tomah, Wisconsin—dubbed “Candy Land” by vets—were 2.5 times more likely to receive higher doses of opioids, and the facility prescribed a risky combination of opioids and benzodiazepines at nearly double the national average at VA medical centers. Opiods are drugs to relieve pain, and include morphine and oxycodone; benzodiazepines are used to treat anxiety, insomnia and alcohol withdrawal among other issues, and include drugs like Xanax and Valium.

The investigation was sparked by an earlier inspector general report stemming from allegations of overprescribing and abuses of authority at Tomah. That IG report concluded there was no conclusive evidence of criminal activity or gross clinical incompetence or negligence, but it said the investigation revealed “potentially serious concerns” that should be brought to the attention of upper management. Sen. Tammy Baldwin, D-Wis., received the report last summer but did not call for an investigation until January after media reports surfaced that a veteran receiving care at Tomah had died of a drug overdose. Baldwin fired a member of her staff over the incident, but has not said much publicly about it so far. Baldwin issued a statement on Wednesday saying the VA’s initial findings “substantiate the troubling concerns my office has heard from current and former employees and patients at the Tomah VA.” She said that the “final result of this investigation must include appropriate corrective action that brings accountability to those responsible for the problems at the Tomah VA and puts in place solutions to prevent these problems and tragedies from ever happening again.”

Baldwin isn’t the only senator taking heat over not acting faster on whistleblower complaints and the IG report. This week Sen. Ron Johnson, R-Wis., said that his office “could have done more to address allegations about opiate prescriptions” at Tomah, according to a March 10 report in USA Today, which says the allegations about problems at the facility fell through the cracks at the congressional staff level last fall.

“The VA’s preliminary findings confirm what my office has been hearing from whistleblowers about the climate of fear and lack of accountability at Tomah,” Johnson said in a statement on Wednesday. “As Chairman of the Homeland Security and Governmental Affairs Committee, I have begun an independent investigation into the tragedies that occurred. Nothing is more important than bringing transparency and accountability to Tomah, and I will work tirelessly to ensure veterans in Wisconsin receive the highest standards of care."

On Monday, the VA announced it was expediting deployment of a tool to help protect vets taking pain pills from overdoses and other risks associated with opioid medications. The so-called “opioid therapy risk report” allows VA providers “to review all pertinent clinical data related to pain treatment in one place, providing a comprehensive veteran-centered and more efficient level of management not previously available to primary care providers.”

VA Deputy Secretary Sloan Gibson met with employees at the Tomah facility on Tuesday. Meanwhile, President Obama this week is scheduled to visit the Phoenix VA medical facility where the scandal erupted over excessive wait times for vets and record falsification, prompting the department reorganization. On March 30, the House Veterans’ Affairs Committee and the Senate Homeland Security and Governmental Affairs Committee will hold a joint hearing on the problems at the Tomah VA health center. 

(Image via Robert Kneschke/