Watchdog: VA Didn’t Dawdle In Treating Vets With Legionnaires' Disease

Pittsburgh VA hospital Pittsburgh VA hospital Keith Srakocic/AP file photo

The Veterans Affairs Department did not drag its feet in treating vets who contracted Legionnaires’ disease during a 2012 outbreak in Pittsburgh, according to a new watchdog report.

VA staff administered antibiotics to patients who tested positive for the Legionella bacteria either before the test was ordered, or on the same date, the inspector general concluded. The investigation stemmed from a 2014 complaint alleging that the department delayed reporting the results of Legionella tests, dawdled in providing treatment to vets in 2012 and improperly collected water samples to obtain false negative bacteria results.

Six veterans died and 16 others became ill from an outbreak in 2011 and 2012 of Legionnaires’ disease, a severe form of pneumonia, in the VA’s Pittsburgh healthcare system.

While the IG “found no evidence of delays in treatment for patients with Legionnaires’ Disease either for those who died or for those who survived,” the watchdog did find that reporting of positive test results in 2012 was “occasionally delayed.” The IG did not substantiate the allegation that water samples collected for Legionella tests were collected improperly. Legionella bacteria can enter buildings from public water sources through the pipes. Preventing the bacteria from entering the environment includes routine testing of water from faucets and other outlets.

An April 2013 VA inspector general report in response to the 2011-2012 outbreak found that the Pittsburgh staff did not conduct routine flushing of hot water faucets and showers, properly document oversight of prevention efforts, or communicate well with infection prevention and facility management staff. The VA’s Pittsburgh Healthcare System serves approximately 360,000 vets in western Pennsylvania, northern West Virginia and eastern Ohio. The system includes three divisions in Pittsburgh and five community-based outpatient clinics in nearby counties.

As for the reporting delays cited in the July 2015 report, the IG found evidence of delays in one out of 6 cases of patients who died of the disease, and in two out of 25 cases of other patients who tested positive for the Legionella bacteria. “Three days elapsed before reporting two results, and four days elapsed for another,” the report said. “We considered the possibility that weekends or holidays may have accounted for additional time and found that only the result reported after four days remained in the laboratory over a weekend.”

Still, according to the watchdog, there was no evidence to suggest that VA failed to treat patients who tested positive expeditiously. The IG made no recommendations in the latest report on the Legionnaires’ outbreak.

In November 2014, the department fired Terry Gerigk Wolf, the senior executive in charge of the department’s health care system in Pittsburgh. Wolf, who had served as director of the VA’s Pittsburgh Healthcare System for seven years, was removed for “conduct unbecoming of a senior executive and wasteful spending.” Wolf was placed on paid administrative leave in June 2014 pending an investigation by VA’s new Office of Accountability Review.

Several lawmakers have criticized VA for being too slow to fire employees involved in numerous scandals, including those related to data manipulation and excessive delays in scheduling doctors’ appointments, and the mismanagement and massive cost overruns associated with the construction of a new VA hospital outside of Denver.

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