Wyden concerned about ‘unacceptable’ conditions at Roseburg VA Health System

Democratic Sen. Ron Wyden of Oregon chairs the Senate Finance Committee, which met on Tuesday, March 12, 2024, in Washington, D.C. (Screenshot from committee webcast)

The Roseburg VA Health Care System failed to evaluate more than half of the veterans under its care for suicide risk when they needed it, a recent federal report has found.

The VA Inspector General, which holds the federal veterans agency accountable for its health care to former servicemembers, found the Roseburg-based veterans system in 2023 failed to provide evaluations for 57% of patients who demonstrated a need for care to lower their risk of suicide. That’s well above the federal threshold of 10%.

In a recent letter to federal veterans officials, Oregon’s U.S. Sen. Ron Wyden called that outcome “unacceptable.” Wyden also said he was concerned about the system’s failure to provide five suicide prevention outreach events a month.

“I recognize that VA leadership attributes these findings to inadequate training and staffing as the reason for Roseburg’s inability to satisfy the stated requirements for reporting and outreach, but these outcomes are unacceptable and ultimately reaffirms the importance of addressing staffing shortages at Roseburg,” Wyden wrote.

The Roseburg veterans system provides primary and specialty medical care to about 40,000 veterans in Douglas, Lane, Coos and Curry counties in Oregon and northern California through its main medical center and clinics. The Roseburg VA Medical Center campus has 32 buildings on a 200-acre campus, and the system operates clinics in Brookings, Eugene and North Bend.

The report, based on a visit in June 2023, also found:

• Staff failed to conduct regular tests of the door alarms for patient sleeping rooms in the psychiatric unit. The alarm manufacturer recommended weekly alarm tests, but staff were unaware of them.
• When medical oxygen equipment started a fire that injured a patient, the system did not conduct an analysis to determine its cause.
• The system struggled in its implementation of a new electronic health record system that affected staff productivity. Some providers could not access the new system and staff had to copy the health information and send it to them.

VA’s  response

VA officials agreed the system needs fixing.

In their response to the report, they said their suicide prevention team will track and audit all reports to ensure patients who demonstrate a risk for suicide are appropriately flagged in their system. And in a memorandum, Teresa Boyd, executive director of the VA Northwest Health Network, said the agency concurred with other findings and recommendations.

Those include ensuring staff conduct a suicide risk evaluation for patients the same day it’s deemed necessary; follow manufacturer recommendations for alarms; and conduct an analysis when major events of patient harm occur.

Sandra Kidd, a spokesperson with the Roseburg system, said officials take the report seriously.

“ In response to the report, we have introduced multiple action plans to address issues concerning suicide risk screenings and recruiting and retention of clinicians,” Kidd said in an email. “We have made significant progress in reducing our vacancy rates for primary care clinicians, currently standing at 22%. This reflects our dedication to improving access to care.”

The agency also uses comprehensive suicide risk evaluations, and staff report missed screenings to the chief of mental health and chief of staff each day for a quick resolution, she said.

“We will continue to work together to serve our veterans and meet their health care needs,” Kidd said.

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