CHARLOTTE, N.C.- Federal inspectors last year found that a Salisbury, N.C., VA nurse, charged with monitoring care for some of the system’s frailest veterans, filed inaccurate reports on their health and listed one as being in “stable” condition 12 days after he had died.

The revelations follow the Charlotte Observer’s report that other VA investigators in 2005 found the Salisbury hospital provided shoddy care and should take “immediate appropriate action to ensure patient safety.” That report detailed the deaths of two veterans who it said received poor care.

The more recent inspection focused on seriously ill veterans that the VA housed in private nursing homes. Five of those homes “did not meet the minimum threshold standards for quality of care,” said the report issued in September by the VA Office of Inspector General. The VA nurse was supposed to visit the patients at least quarterly, but she had not done so for more than two years.

Inspectors said her “infrequent progress note entries” listed all patients as stable, but they found some had been hospitalized and experienced “significant weight loss.”

The nurse, who was not named in the report, is still with the Salisbury hospital, spokeswoman Carol Waters said in an e-mail. She is no longer responsible for nursing home visits, Waters said.

Oscar Aylor, a UNC Chapel Hill professor, said the nurse would have been fired for such an “incredible” offense at civilian hospitals he has helped run. He called the 2006 report egregious, especially coming on the heels of other serious problems.

“There are probably no words to express how bad it is,” said Aylor, a professor of health policy and administration. “The culture of the hospital, it appears, is not serious about quality. It is very disturbing and very alarming to see these things continue to happen.”

Donald Moore, who was the Salisbury hospital’s director at the time of both reports, told the Observer that the case with the nurse was one of the most serious during his tenure, but he said “It was poor charting. It wasn’t as bad as it seems, though I know that sounds crazy.”

“You talk to the physicians in charge (of the nurse) and they thought she was a good employee,” he said. “The feedback on her was very positive. We had over 1,700 employees, and somebody will drop the ball.”

He said he suspended the nurse and her supervisor.

Moore took over Salisbury in June 2004, and last November became head of the VA hospital in Phoenix. In an interview at his home in nearby Tempe, Ariz., Moore said that while in Salisbury, he tried to improve what he said was the hospital’s poor reputation among vets.

“We worked hard to change the quality of the medical staff,” he said. “We removed more physicians in the two-and-a-half years I was there than in the previous 30 years. We raised the bar. Salisbury was a sleepy little place where people came to retire. We made it where marginal performers couldn’t survive.”


The VA contracts with private nursing homes to provide long-term care because some hospitals don’t have the necessary facilities or don’t have room for all eligible veterans. A VA hospital nurse is supposed to visit at least quarterly, the 2006 report said.

The inspectors reviewed records for 10 of 17 veterans in nursing homes and found the nurse visited on “rare occasions” when requested but made no follow-up visits in more than two years. The nurse told inspectors she didn’t have time to make the visits but reviewed information from the nursing homes’ staff. Her notes “indicated that all patients were stable,” the report said. “She signed one such note on a patient 12 days after his death.”

It identified no patients.

“The nurse wasn’t doing what she was supposed to be doing, clearly, but she was having the nurses at the nursing home send her information,” Christa Sisterhen, associate director at the VA office that did that investigation, said.

The report says veterans in the nursing homes are “aging, frail and often mentally and/or physically disabled” and require the monitoring of a registered nurse “to assure appropriate care.”

The hospital responded to Observer questions only by e-mail and did not make management available for interviews.

Waters, the Salisbury spokeswoman, said hospital staff evaluated all patients in the nursing homes within three weeks of the 2006 report, “and the care was found to be excellent.”


The report was the result of a routine inspection by the Office of Healthcare Inspections in Atlanta. The unit is part of the VA Office of Inspector General responsible for monitoring veterans’ health care. Another VA branch, the Office of the Medical Inspector, did the 2005 inspection following an anonymous tip alleging more than 12 suspicious deaths at Salisbury.

Sisterhen said she didn’t know about the earlier report.

The 2006 report also found that the Salisbury hospital stopped “peer reviews” in which doctors analyze patient care and seek to prevent future problems. Waters said that hospital staff “continued to monitor patient safety and the quality of care during the time in question.” But hospital management stopped the review process, fearing they’d have to release findings in response to an employee complaint filed with another federal agency.

All hospitals should do the reviews, Aylor said.

“It is a measure of quality of care,” he said. “If you are not doing that, it’s just sloppy.”

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For more information on veterans and military health issues, see McClatchy Newspapers’ “Wounded Warriors” blog: http://washingtonbureau.typepad.com/veterans/

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(c) 2007, The Charlotte Observer (Charlotte, N.C.).

Visit The Charlotte Observer on the World Wide Web at http://www.charlotte.com/

Distributed by McClatchy-Tribune Information Services.

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