OSC Notes Confusion Over Patient Restraint Policies at VA Albany Medical Center, Finds Corrective Action Encouraging
November 08, 2017
OSC today wrote President Trump and publicly revealed the results of an investigation by the VA into whistleblower allegations of instances of excessive use of physical restraints.
The U.S. Office of Special Counsel (OSC) today wrote President Trump and publicly revealed the results of an investigation by the Department of Veterans Affairs (VA) into whistleblower allegations of instances of excessive use of physical restraints at the Samuel S. Stratton VA Medical Center (VAMC), in Albany, N.Y.
The whistleblower in this case, a former nurse manager at the Albany facility, alleged that in at least two instances, psychiatrists physically restrained a patient for excessive lengths of time – in one instance for as long as 49 hours – in violation of VA regulations, policies, and rules. She contended that these and other incidents demonstrated a disturbing pattern of psychiatrists’ making determinations to continue or discontinue restraints based on their schedules or convenience, rather than the needs and welfare of the patients. While the VA did not find such a pattern nor conclude that restraints in the two specific instances alleged were excessive, it did substantiate two instances of improper patient care and concluded that these actions constituted a violation of law, rule, or regulation and a substantial and specific danger to public health and safety.
After reviewing the VA’s reports, OSC determined that the VA’s findings did not appear reasonable. The VA’s reports focused largely on the whistleblower’s actions rather than whether treating psychiatrists had complied with VA regulations and rules governing patient restraint. OSC found that the agency’s reports presented conflicting evidence and changing rationales that did not fully support the VA’s findings regarding the restraint incidents reported.
“The reports also demonstrate confusion and/or a lack of knowledge of VA rules and policies on the restraint of mental health patients, including the policies and procedures that were in place at the VAMC at the time of the incidents described,” Special Counsel Henry J. Kerner wrote to the President. “Nevertheless, OSC is encouraged that the VA has taken appropriate corrective action, including the implementation of and training for a revised policy and procedures that are now in place at the VAMC.”
As required by statute, OSC sent a copy of its letter, an unredacted version of the agency reports, and whistleblower comments to the Chairmen and Ranking Members of the Senate and House Committees on Veterans’ Affairs. OSC also filed a copy of the letter to the President, redacted reports, and whistleblower comments in its public file. This matter is now closed.