More than 200 veterans have died while waiting for medical care at the Department of Veterans Affairs hospital in Phoenix, two years after the facility was at the center of a scandal in which patient records were altered to hide the length of their waiting period.
In a report released Tuesday, the VA Inspector General's office (OIG) found that 215 deceased patients had open specialist consultation appointments at the Phoenix facility on the day they died. The report also found that one veteran never received an appointment for a cardiology exam "that could have prompted further definitive testing and interventions that could have forestalled his death."
The Phoenix system was at the center of a national scandal in 2014 when Veterans Affairs internal investigations identified 35 veterans who died while awaiting care. Veterans on secret waiting lists reportedly faced scheduling delays of up to a year.
The revelations led to the resignation of then-VA Secretary Eric Shinseki.
Despite two years of reform efforts, the OIG report found that the Phoenix hospital still has "a high number of open consults because ... staff had not scheduled patients' appointments in a timely manner (or had not rescheduled canceled appointments), a clinic could not find lab results, and staff did not properly link completed appointment notes to the corresponding consults."
Consults include appointments, lab tests, teleconferencing and other planned patient contacts.
As of July 2016, there reportedly were 38,000 open consults at the Phoenix VA.
The report also found that nearly a quarter of all specialist consultations in 2015 were canceled, in part due to employee confusion stemming from outdated scheduling procedures that were not updated until this past August.
Rep. Jeff Miller, R-Fla., chair of the House Committee on Veterans Affairs, said the report proved that the work environment at the Phoenix VA "is marred by confusion and dysfunction" and the problems won't be solved "until there are consequences up and down the chain of command."
Arizona Sens. Jeff Flake and John McCain released a joint statement calling the practices described in the report "unacceptable" and "reprehensible."
"Today's report confirms that cultural change at the Phoenix VA is still desperately needed," McCain and Flake said. "There is no place at the VA for managers and employees to engage in such misconduct."
The VA released its own statement touting its reform efforts and calling for increased support staffing. According to the department, the Phoenix facility has 39 job openings among the support staff responsible for consultation scheduling.
The Phoenix system enrolls about 85,000 veterans and announced last week the hiring of yet another new director since the 2014 firing of Sharon Helman.
The Associated Press contributed to this report.