Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia

The VA Office of Inspector General’s (OIG) Office of Investigations was contacted by the Facility Director in June 2018 who reported concerns related to the suspicious deaths of nine patients from profound hypoglycemia (low blood sugar). A criminal investigation was initiated. The OIG Office of Healthcare Inspections immediately commenced a parallel healthcare inspection. Healthcare inspectors finalized their evaluation after OIG investigators completed the criminal case. On July 14, 2020, Reta Mays, a former nursing assistant, pled guilty to seven counts of second degree murder and one count of assault with the intent to commit murder by deliberately administering insulin to eight patients. The OIG found that the facility had serious clinical and administrative failures, including hiring and medication security practices, communication of clinical information, and patient safety deficiencies that contributed to Ms. Mays’s criminal actions not being identified and stopped earlier. The OIG made three recommendations to the Under Secretary for Health related to adjudicator follow-up of unreturned background investigation documentation, rescue medication security and management, and mortality data analyses. Two recommendations were made to the Veterans Integrated Service Network Director to conduct management reviews of the care of patients discussed in this report and a broader evaluation of patients who may have been harmed in other ways by Ms. Mays’s actions. Ten recommendations were made to the Facility Director related to the Pharmacy Service’s inventory accountability, endocrinology consults, clinical communication expectations, clinical documentation reviews, clinical care-related reporting expectations, patient safety event training, interdisciplinary mortality workgroup activities, oversight and reporting, and a culture of safety.