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U.S. Office of Special Counsel

1730 M Street, N.W., Suite 201

Washington, D.C. 20036-4505


(202) 653-7984               

    The U.S. Office of Special Counsel (OSC) today transmitted to President Bush and the Congress an investigative report substantiating a whistleblower’s allegations that two supervisory nurses at the Eugene J. Towbin VA Medical Center (VAMC) in North Little Rock, Arkansas, engaged in inappropriate and abusive behavior that endangered the health and safety of elderly and disabled patients.

    The whistleblower, a Licensed Practical Nurse, provided information to OSC alleging that a Charge Nurse in the extended care unit of the VAMC verbally abused patients and neglected patients’ personal and hygienic needs. The whistleblower described multiple incidents when she witnessed the Charge Nurse yelling at patients, depriving them of meals, and otherwise mistreating them. She alleged that, in addition to abusing the patients, the Charge Nurse failed to follow VAMC procedures for reporting patient accidents and falls.

    The whistleblower also alleged that a Nurse Manager in the extended care unit, on at least three separate occasions, interrupted her while she was distributing medication to patients in order to discuss non-urgent administrative matters. The whistleblower stated that, each time this occurred, she vehemently objected to the interruption, but the Nurse Manager persisted. She alleged that, as a result of the delay, patients did not receive their medications at the prescribed time, including diabetic patients requiring time-sensitive doses of insulin. 

    Special Counsel Elaine Kaplan concluded that there was a substantial likelihood that the information the whistleblower had provided disclosed a substantial and specific danger to public health and safety. By law, where the Special Counsel makes such a substantial likelihood determination with respect to a whistleblower’s disclosures, the agency involved, in this case the Department of Veterans Affairs (VA), is required to conduct an investigation of the disclosures and report its findings and any planned corrective and/or disciplinary actions to the Special Counsel. 

    After the Special Counsel transmitted the disclosures to the Secretary of the Department of Veterans Affairs, the agency convened an Administrative Board of Investigation to look into the allegations. Based on testimony provided by several current and former employees in the unit, the Administrative Board arrived at the following conclusions about the behavior of the Charge Nurse: (1) she verbally abused and mistreated patients, (2) her nursing skills were below the acceptable standard of care, (3) she was willfully idle on the job, and (4) she failed to follow VA policy and procedures for reporting patient falls. The Administrative Board also concluded that the Nurse Manager had (1) inappropriately interrupted patient care, (2) verbally abused patients, (3) taken food items from patients without their permission, (4) failed to report the abusive behavior of the Charge Nurse, (5) engaged in negative interactions with her subordinates, (6) violated agency policies and procedures governing the assignment of light duty work to sick or disabled employees, and (7) retaliated against employees who complained by mishandling their schedule and leave requests. Lastly, the Administrative Board found that the unit’s educational needs were not adequately met and staff meetings were held infrequently. 

    The agency report also included a description of actions taken or planned in response to the findings of the Administrative Board of Investigation as well as the findings of a parallel investigation, examining many of the same allegations, conducted by the VA Office of the Inspector General. Among other actions taken, the report states that (1) the Chief, Nursing Service, proposed termination for the Nurse Manager and the Charge Nurse; (2) the facility initiated procedures to report the Charge Nurse and Nurse Manager to the State Licensing Boards; (3) the facility implemented a new tracking system to ensure that all patients receive their meal trays or tube feedings as scheduled; and (4) the nurses in the unit received additional training on the proper administration of medications, the importance of nutritional intake, and handling patient/family concerns. According to the agency report, the Charge Nurse subsequently resigned, effective June 5, 2002, and the Nurse Manager resigned, effective July 12, 2002.

    In transmitting the agency report to the President and the Congress, the Special Counsel is required by statute to evaluate whether it contains the necessary information and whether its findings appear reasonable. Special Counsel Elaine Kaplan found the Department of Veterans Affairs report met these requirements. She also found that the agency has taken appropriate corrective and disciplinary action with respect to the report’s findings.

    Among its other functions, the Office of Special Counsel provides federal employees with a secure channel for blowing the whistle on violations of law, rule or regulation, gross mismanagement, gross waste of funds, an abuse of authority, or a substantial and specific danger to public health and safety. OSC requires agencies to conduct investigations whenever it finds a substantial likelihood that a federal employee’s disclosures demonstrate the existence of one of these conditions. The agency must then report its findings as well as any corrective action taken to OSC. After OSC reviews the report to ensure that it contains the necessary information and that its findings appear reasonable, OSC transmits the report to the President and the Congress for further action, if appropriate.

    Copies of the report from the Department of Veterans Affairs can be obtained by contacting OSC.