March 22, 2007
Increased Deaths, Grim Conditions Reported by GAO
By Steve Vogel and Michael E. Ruane, Washington Post Staff Writers
Reports of a rising death rate and rooms spattered with blood, urine and feces at the Armed Forces Retirement Home prompted the Pentagon yesterday to begin investigating conditions at the veterans facility in Northwest Washington.
The Government Accountability Office warned the Pentagon this week that residents of the home "may be at risk" in light of allegations of severe health-care problems. Residents have been admitted to Walter Reed Army Medical Center with "the most serious type of pressure sores" and, in one case, with maggots in a wound, according to a GAO letter sent to the Defense Department.
Timothy Cox, the chief operating officer for the retirement home, said yesterday that the accusations are "without merit," and he blasted the GAO for making "inflammatory allegations" without investigating them.
The reports came from medical personnel who treat residents at the historic veterans home, formerly known as the U.S. Soldiers' and Airmen's Home. The facility, run by an independent federal agency under the jurisdiction of the Department of Defense, is home to more than 1,100 enlisted retirees, many of them veterans of World War II, Korea and Vietnam.
The Pentagon sent a team of four doctors on an unscheduled visit yesterday morning to view the conditions and speak to officials and residents. The team was appointed Tuesday in response to the letter sent a day earlier to Secretary of Defense Robert M. Gates by David M. Walker, the comptroller general and head of the GAO.
The letter reported allegations that inspectors received during its "oversight and monitoring" of the home, mandated by Congress in 2005. According to Walker's letter, the allegations include a "rising number of resident deaths," an increase in the rates of admission to Walter Reed, resident rooms befouled with human waste, and veterans suffering from bedsores.
"GAO believes that these allegations should be examined because AFRH residents -- a vulnerable population of elderly, enlisted, military retirees -- may be at risk," Walker wrote.
Those who raised questions about the medical care have suffered retaliation from the private company that manages the veterans home, the medical personnel told GAO investigators.
During a tour of the home yesterday, Cox confirmed that a resident had been found in August with maggots in a leg wound. Cox said the man was "noncompliant and combative," and did not want his dressing changed.
Cox said the dressing should have been changed anyway. Eight employees were eventually fired because of the incident, he said. The man, who was 87, later died of causes unrelated to the wound. "It was an isolated incident," Cox said.
Cox said the reports of human waste in the rooms may have stemmed from an outbreak in February of highly contagious norovirus, which infected more than 100 residents. "When you're sick with vomiting and diarrhea, sometime you miss the john," he said.
Cox said the home's death rate has gone up from about 13 to 15 a month, but he attributed the rise in part to a new hospice program.
In addition, the home received an influx of veterans after Hurricane Katrina damaged a sister institution for Navy veterans in Gulfport, Miss. Cox said the Washington home now has 150 residents requiring assisted living, twice as many as before the hurricane.
Sens. Carl Levin (D-Mich.) and John McCain (R-Ariz.) sent a joint letter to Gates on Tuesday saying they were "dismayed" by the GAO letter and calling on Defense "to immediately undertake an independent investigation."
The home on North Capitol Street, founded in 1851, has long been funded by a 50-cent paycheck deduction paid by all enlisted personnel. Cuts in the size of the military force after the end of the Cold War decreased income for the home. By the late 1990s, the home was in danger of bankruptcy.
Cox was hired from private industry in 2002 to bring down costs. In the past three years, the workforce has been cut from 736 to 447, and the operating budget has been reduced from $76 million to $54.7 million, according to figures provided by the home. The maintenance staff has shrunk from 127 to nine, despite a rising population, according to the senators' letter.
A group of veterans living there filed a federal class-action suit against the home and the Defense Department in 2005, claiming budget cuts have harmed care for residents. Court-ordered mediation talks are to begin next month, said Martin Cody, a resident.
Several residents interviewed yesterday said they were generally happy. Some complained of long lines at the medical clinic in the mornings and said they thought the home lacked enough doctors.
"You cannot make everybody happy," said George DeMonfort-Proksa, 82, a veteran of the Polish air force and the U.S. Army who has lived at the home 19 years. "You'll always find people who will be miserable."