AUGUSTA, Ga. (WRDW/WAGT) – A new inspection found a toxic workplace culture at the Department of Veterans Affairs health care system in Augusta and other problems that could hinder patient care.

A report said the inspection in September uncovered “concerning behavior and communication problems among facility leaders.”

The last time the Office of Inspector General was in 2910, and now it’s released another report that finds leadership remains a problem.

In the new report, inspectors said they found:

• Leaders had a threatening and abusive communication style.
• There was retaliation for employees sharing concerns with leaders.
• A toxic workplace that led to a culture of fear and employees feeling psychologically unsafe.
• There were trust issues between frontline staff and quality management staff, which hindered collaboration on patient safety efforts.
• Employees “felt supported by their immediate supervisors but lacked trust with facility leaders.”

Some of the concerns echoed what had been found in a 2019 inspection.

Six years later, retaliation is a recurring theme.

Employees said reporting concerns is met with retaliation in the form of removal from positions, reassignment to other facilities and punitive investigations.

Employees reported feeling fearful of losing their job if they speak out or ask for help.

The report notes that the director said survey scores for fear of reprisal and psychological safety had improved but acknowledged they remained low when compared with other facilities.

The report also outlines staffing problems.

A human resources specialist reported there were 36 vacant primary care positions. The chief and two medical director positions had been vacant longer than 12 months. Leaders described using salary adjustments as well as relocation and retention bonuses as strategies for recruitment.

However, the report found there is an ongoing problem with staff retention, not recruitment. The report states that until leaders address these systemic issues, the problem will persist.

The staffing issues led veterans to have concerns about changes in primary care providers.

The inspectors reviewed the facility’s veteran enrollment following PACT Act implementation and determined that it increased from October 2020 through March 2024.

However, 34 of the facility’s 39 primary care team panels were at or above capacity.

Appointment wait times ranged from five to eight days for established patients, and five to 14 days for new patients over the past two years.

Staff reported the workload may have caused providers to miss important notifications in the electronic health records or delay their responses to address them.

Also, there were supply chain management concerns, which were repeat findings from two prior reports.

The staff told inspectors the supply issues affected their ability to provide safe patient care.

They gave an example of a patient whose care was delayed because of the unavailability of a stent to keep an artery open for a crucial procedure. The patient later died.

The Office of Inspector General was unable to determine whether the unavailable supplies contributed to the death. But a nurse leader said the lack of supplies contributed to the delay in care.

The director responded to the allegations, saying the supplies were not located in the supply closets but were stored in various other areas within the units and that staff was hoarding supplies.

The director responded to the report, saying the Augusta leadership team will focus on improved communications, individual development and healthy relationships for the entire organization.

The report also had some positive things to say:

• The staff effectively identified and enrolled veterans into homeless programs and met housing, medical, and justice needs.
• Facilities were clean, with no privacy concerns. Each main entrance offered clear signage, navigation assistance, and other tools to help veterans with visual and hearing sensory impairments.

READ THE REPORT:

The report listed five recommendations:

• The undersecretary for health should evaluate facility leaders for appropriate supervisory behavior and professional communication and take actions as needed. The report notes that the Office of Inspector General “identified repeated concerns and findings from a previous report related to leaders’ communication issues and unprofessional behavior that affected staff’s ability to work in a psychologically safe environment.”
• The undersecretary for health should determine “whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.”
• The undersecretary for health should ensure “the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.”
• Facility leaders should develop action plans to ensure providers communicate test results to patients in a timely manner.
• The undersecretary for health should direct the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and take action as needed.

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