On Feb. 20, 2023, a 77-year-old man was admitted to the intensive care unit at Aurora’s Rocky Mountain Regional VA Medical Center for chronic kidney disease.
Two weeks later, nurses and doctors grew concerned after learning the man’s significant other, unbeknownst to ICU staff, had been giving him a tincture under his tongue while he slept.
The care team didn’t know what was in this remedy. Yet ICU leadership instructed nurses to keep giving it to the patient, telling clinicians that the hospital’s chief of staff, Shilpa Rungta, approved the tincture, internal emails show.
“I do not discredit that we honestly have NO idea what is in it, and have been taking (the caregiver’s) word for it, but if something happens to (the patient) and it is deemed that it was caused by this ‘patient’s own medication’ it does not fall on us,” Melissa Nickerson, the ICU nurse manager, wrote in the email to intensive care staff, which was reviewed by The Denver Post.
Multiple VA clinicians refused to give the unknown medication, they told The Post, fearing they might be at risk of losing their license or getting sued. Several said they submitted complaints to the U.S. Department of Veterans Affairs’ Office of Inspector General, which conducts independent oversight of the sprawling federal agency.
“The message from leadership: ‘Shut up and do what you’re told,'” said one VA employee, who spoke to The Post on the condition of anonymity for fear of retribution. “‘Don’t go with your gut. Don’t follow protocol.'”
This case represents just one example of what whistleblowers say are persistent patient safety issues in the VA’s ICU, which is tasked with treating the sickest veterans admitted to the Aurora hospital.
Interviews with a half-dozen critical care providers, along with internal VA emails, show the ICU used COVID-era staffing workarounds long after the public health crisis eased. This means nurses were asked to care for more patients than is generally considered acceptable, and untrained nurses were tasked with helping critically ill veterans.
VA leadership even brought in outside providers three years ago to assess the ICU’s health and provide recommendations to improve practices. Workers say, though, that a committee convened to tackle the issues met once and never again.
When clinicians do raise concerns to management, they say they’re met with admonition and retaliation. “People don’t know that if they went across the street they’d get better care,” the VA employee said.
The allegations in the ICU come as the Aurora VA has been roiled by controversy in recent months.
In October, VA leadership removed the Eastern Colorado VA’s director and his chief of staff over concerns about “operational oversight, organizational health and workplace culture.” More than a dozen VA employees described to The Post a culture of fear and a hostile work environment among the 4,000-person workforce. A federal investigation into the oversight concerns is ongoing.
The Post reported in November that the head of the hospital network’s prosthetics department was canceling veterans’ orders to eliminate a backlog, prompting congressional oversight from U.S. Rep. Jason Crow. The head of the VA’s nationally renowned suicide prevention center, meanwhile, was reassigned following The Post’s story outlining a toxic workplace culture rife with “emotional, mental and psychological abuse.”
Aurora VA officials declined multiple interview requests for this story. Officials had offered an interview to The Post in January, but withdrew the offer after learning the topics the reporter wanted to discuss.
In an email, an agency spokesperson said they could not comment on the ICU issues due to an ongoing investigation. The VA declined to answer any specific questions.
After The Post published this story online, the director of the VA’s Rocky Mountain region, Sunaina Kumar-Giebel, told The Post in a statement that the agency is “actively looking into these allegations and safety concerns, and we are conducting further investigations to correct any current processes that are not upholding the highest standards of care.”
She added that the VA seeks to restore a working environment in which staff feel they can feel heard and raise concerns.
“No regard for patient safety”
During the height of the pandemic, the Aurora VA — like other hospitals across Colorado and throughout the nation — received an onslaught of patients that strained its capacity.
The hospital, in response, instituted emergency practices related to staffing and nurse-to-patient ratios that went beyond normal procedures.
But the Aurora VA allowed some of these practices to remain in place well after the crisis eased, multiple ICU workers told The Post.
Up until December, staffing shortages at times pushed the ICU to assign each nurse three patients when standard nursing protocol dictates they should only have two, multiple employees told The Post. Nurses caring for stepdown patients — those transferring out of intensive care — are supposed to have a maximum of three patients, but instead they were tasked with caring for as many as four at a time, the staffers said.
“There’s no regard for patient safety,” said one critical care provider, who spoke on the condition of anonymity for fear of retaliation.
Nurses, beginning in 2020 and continuing to the present, have flooded their union representatives with objection letters. The notices — called “assignment despite objection” letters — allow nurses to inform the union when they’re given assignments that they feel could be unsafe for patients or staff.
The letters, some of which were reviewed by The Post, said inadequate staffing levels meant nurses could not handle situations in which a patient or visitor went missing. One 2023 letter stated inadequate staff impacted care for acute patients and those with behavioral issues.
A February 2024 staffing chart, reviewed by The Post, still showed personnel levels significantly below target goals for nearly every shift. On Feb. 23, for example, there should have been 16 nurse-hours spent on the average ICU patient, but the VA could only allocate 11 nurse-hours, the data shows.
The hospital’s executive leadership team “is upset with nurses for complaining about staffing,” one provider wrote in a September 2022 email to union brass. “I see the burnout in all of the nurses. It is very disheartening to watch.”
Sharda Fornnarino, an Aurora VA nurse and president of the National Nurses United union, said the hospital is short nurses in all but one unit across the facility, including psychiatry, the emergency room and the spinal cord injury unit. The Rocky Mountain Regional Medical Center, in an August survey, reported severe shortages in 34 nursing occupations.
Nurse-to-patient ratios are higher in other units in addition to the ICU, Fornnarino said. The spinal cord injury unit, for example, should have one nurse for every four patients, she said. Sometimes nurses in that unit are given as many as six patients, she said.
“It concerns me we’re not going to give the proper care that’s needed,” Fornnarino said.
Several states — though not Colorado — have laws concerning nurse-to-patient ratios. California mandates hospitals stick to two patients for every nurse in intensive care units. Massachusetts law prohibits more than one patient per nurse in most cases in the ICU. They’re forbidden to take a third patient.
“There’s a slew of evidence that if it goes beyond two patients in the ICU it can become precarious,” said Pamela B. de Cordova, an associate professor at Rutgers University’s School of Nursing.
The risks, she said, can be serious: Without full attention from staff, patients could fall; central lines could be infected; sick individuals could develop ventilator-associated pneumonia.
A 2010 study in Health Services Research found lower nurse-to-patient ratios were associated with significantly lower mortality. When nurse workloads were in line with California-mandated ratios, nurses’ burnout and job dissatisfaction were lower, and workers reported consistently better quality of care.
With fewer nurses available, VA leaders instituted a system known as “team nursing,” multiple ICU workers told The Post. Under this model, a nurse assigned three ICU patients would be assisted by a certified nursing assistant or nurse from another department.
The problem, ICU providers say, is that floor nurses are not trained to work in the intensive care unit. They’re not trained to handle ventilators, for example, or continuously monitor cardiac rhythms.
“Their stance is ‘a nurse is a nurse is a nurse,'” said the critical care employee who spoke about the nurse-to-patient ratios. “They take you from one specialty to another that you’re not properly trained on. You’re not trained to care for those patients.”
Lee Parmley served as the Eastern Colorado VA’s chief of staff when COVID hit in 2020, and was part of the leadership group that instituted the team-nursing model as the hospital was inundated by the surge in patients.
He said he was surprised to learn the hospital was still using this framework — well after the public health crisis had abated. Team nursing, Parmley said, shouldn’t be used to keep the hospital at a minimum staffing level. And ICU nurses should not take care of more than two patients, he said.
“I don’t see any reason why they would still be in that fallback position,” Parmley said.
Denver Health, by comparison, uses one nurse for every two ICU patients — a ratio that remained consistent even during COVID, a spokesperson said. The hospital does not send nurses from other departments to the intensive care unit.
The Colorado Hospital Association, in its literature, says most ICUs are staffed with one nurse to every one or two patients — though it acknowledged that circumstances can vary at federal and specialty facilities such as the VA.
To keep nurse ratios at accepted levels, the VA has been downgrading ICU patients to lower acuity beds before they’re ready, multiple providers told The Post. In six to eight instances since January, a patient has been downgraded prematurely, only to end up back in the ICU, the critical care worker, who’s been part of these conversations, said.
“They decide they’re going to downgrade because we don’t have enough staff,” this individual said. “If they truly are ICU patients, they ought to be getting that care.”
ICU management, in a meeting this month, advised staff to be “creative on patient assignments,” according to meeting minutes reviewed by The Post.
Janelle Beswick, a VA spokesperson, said in a statement that the Aurora VA faces many of the same challenges with staffing as other hospitals. The VA continues to “aggressively recruit top talent,” she said, using competitive pay structures.
Nursing shortages are hardly unique to the Aurora VA. Ninety-two percent of VAs nationwide reported severe shortages for nurses, according to the 2023 Office of Inspector General report.
Colorado, even outside the VA system, faces a lack of nurses statewide. A 2021 study from Mercer found the state ranked in the top five in terms of need, with an estimated shortage of 10,000 registered nurses by 2026.
In the wake of the pandemic, about 100,000 registered nurses left the workforce nationally due to stress, burnout and retirement, according to a study last year by the National Council of State Boards of Nursing.
Maryann Alexander, the organization’s chief officer of nursing regulation, said the mass exodus “will become a greater crisis and threaten patient populations if solutions are not enacted immediately.”
The mystery tincture
For frontline workers, the instruction to administer the unknown tincture last year raised serious concerns over management’s adherence to medical standards.
Nickerson, the ICU’s nurse manager, told providers in the March 11 email that the hospital was following policy. (She did not respond to messages seeking comment.)
VA statute states medications acquired from sources outside the VA are prohibited unless authorized by the chief of staff. Medications, including herbal remedies brought in by patients, “will not be used for inpatient administration” except for research purposes, or if the inpatient pharmacy is unable to supply them and they “are critical to a patient’s care” — such as oral chemotherapy.
Multiple nurses told The Post they refused to give the mystery remedy, citing these policies and state nursing guidelines surrounding the administration of unknown medications.
One of the doctors was so concerned that, the day after Nickerson’s email, they ordered a blood test for heavy metals — an unusual test for ICU patients, one clinician told The Post.
The patient died March 15. The test showed low levels of arsenic in the man’s system, though well within the “normal range,” according to his autopsy report. The Adams County coroner ruled the manner of death to be natural, caused by sepsis.
The autopsy report noted the patient had been taking a homeopathic medication, delivered by his family, from Feb. 20 to March 7 “without the hospital’s knowledge.”
But experts raised alarm that the VA would have allowed this unknown substance to be given at all — let alone by the hospital’s own providers once it was discovered.
“That’s not what I would consider standard practice,” said Parmley, the VA’s former chief of staff. “I would certainly not have done that.”
He said he was happy to hear that providers were uncomfortable giving this remedy. “They should have been,” he said.
Rungta, the then-chief of staff who approved the unknown medication, did not respond to messages from The Post seeking comment. She was reassigned from the position in October amid the VA’s investigation into oversight and workplace culture concerns.
Another incident in October raised more red flags about ICU practices.
A patient had a code blue — or medical emergency — on the hospital floor, according to a VA staff member who spoke to The Post about the ICU ratios. The individual needed to go to the ICU immediately, but there were no open beds.
Staff previously had pleaded with leadership to leave one bed open for these situations but were denied, multiple workers told The Post. Many hospitals leave a bed open for these types of cases — known as a “crash bed” — though it’s not uniform in every institution.
With no open beds, providers were forced to pull a patient out of one of the rooms without a thorough cleaning, a practice known as a “dirty bed swap,” the staffer who witnessed the incident said.
A full cleaning between patients normally takes 45 minutes, the employee said. The swap took 15 minutes.
Parmley, the former VA chief of staff, said this “certainly sounds like a substandard practice.”
“That shouldn’t be necessary, ever,” he said.
Staff raised concerns about “dirty bed swaps” in early 2023 to VA leadership, including former director Michael Kilmer, who thanked the employees for bringing it to his attention, according to emails reviewed by The Post. Sharee Taylor, the Aurora VA’s associate director, instructed workers to let her know if they see the practice again “as this is not acceptable for patient care.”
Kilmer and Taylor did not respond to messages seeking comment.
But clinicians say the potential for “dirty bed swaps” remains in place, though staff could not recall another instance in which it happened. The idea that it could happen again, though, makes clinicians extremely nervous, they said.
The Las Vegas report
VA leadership sought external help with the Aurora hospital’s ICU as early as 2021.
That year, VA management brought in a group of executives from the Las Vegas VA system to audit and provide recommendations to the Aurora team. After shadowing and observing hospital staff, the Nevada group compiled a report, identifying shortcomings and areas for improvement, according to a copy of the report reviewed by The Post.
The document noted a variety of concerns, including managers not reviewing safety events or lessons learned with staff. Frequent leadership changes, meanwhile, had led to a “fractured and inconsistent management style,” leaving nurses confused about which directives to follow.
Another finding said that the structure of medical coverage in the ICU creates a “complicated and unsafe practice environment.” The ICU hiring new graduates, the report states, “is inherently dangerous.” The document noted that nurses complained about being short-staffed but that the “data doesn’t support this.” (In interviews with The Post, nurses pushed back on how leadership defines “short-staffed.”)
Aurora VA leadership, after the report’s conclusion, convened a committee to gather input from the frontline workers who would be implementing the report’s recommendations.
The group met on April 29, 2021, breaking down the report and telling the committee members they had a lot of work cut out for them. Leadership delegated certain tasks and agreed to meet again to discuss.
But there was never another meeting, according to one committee member.
“Radio silence,” this VA employee said, speaking on the condition of anonymity for fear of retribution. “It was their way of saying, ‘We care about your input.’ They didn’t actually want our input or us to be involved. This was their way of crossing off something on their list.”
Dr. Ronald Robinson, who served as the Aurora VA’s deputy chief of staff during this time, acknowledged that leadership did not follow up on the report effectively.
“It was more incompetence than willful intent,” Robinson said.
The committee and lack of follow-up exemplifies the culture inside the Aurora VA’s ICU, staff say. Workers are encouraged to bring up concerns but then feel unheard or punished when they do. The ICU workers’ accounts mirror those from other VA employees, who told The Post last year about the culture of fear and retaliation across myriad departments.
“Leaders say, ‘We have an open-door policy,'” said another clinician, speaking on the condition of anonymity due to fears of retaliation. “But it’s a contradiction. You don’t go against chain of command.”
“It’s lose-lose,” this individual said. “An impossible situation.”
Another worker said she’s embarrassed to say she works at the VA.
“The ‘VA way,'” this person said, “has a negative connotation now.”
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