By Alex Cameron, 9 Investigates
OKLAHOMA CITY -- The chairman of the state Senate's Veterans Affairs Committee calls it "a slap in their face of every veteran that's ever served our nation." Senator Frank Simpson is talking about Oklahoma's recent record of shameful care for its most vulnerable veterans.
The state has approximately 1,500 beds at its seven veterans centers. The residents -- veterans of all branches and numerous conflicts -- are mostly advanced in age and in poor health. In many cases, they are in the centers because their families can no longer provide them the level of care they need.
"We should be doing everything we can to make sure that they are comfortable, and that their needs are being met," said Sen. Simpson, "because we owe them a tremendous, tremendous price."
Frances Minter, whose husband, Jay, was a resident at the Claremore Veterans Center, knows as well as anyone that the state hasn't kept up its end of the bargain.
"Here's where you can see where the skin just sloughed," said Minter, referring to a graphic photograph of her husband's legs, "you couldn't touch anywhere, it just peeled right off."
On May 2, 2012, what should have been a routine whirlpool bath for the 85-year-old New Mexico native, left the World War II vet badly wounded.
"He was screaming, 'they burned my legs, they burned my legs,'" Minter recalled, repeating the words she heard from her husband, as she entered his room that day.
Very early the following morning, Jay Minter passed away. A subsequent examination by the state Medical Examiner determined he died from second-degree burns, which covered more than half of his body.
Frances Minter says his fatal injuries were the result of both faulty equipment and neglect.
In fact, an investigation showed the tub's thermometer wasn't working, and the nurse's aide who had placed Minter in scalding hot water and was supposed to watch him -- at the same time she was bathing three other men -- didn't pay close enough attention to him.
The Nine Investigates team reviewed the last five years of inspection reports for the state's veterans centers -- Ardmore, Claremore, Clinton, Lawton, Norman, Sulphur, and Talihina -- and uncovered wide-ranging cases of abuse and neglect.
- at the Norman facility, a resident died, one day after being dropped by staff
- in Ardmore, a resident was raped by a nurse aide
- in Clinton, a resident was hit multiple times in the face
Related Link: See the 2010 inspection report for the Claremore Veterans Center
Related Link: See the 2011 inspection report for the Ardmore Veterans Center
Related Link: See the tort claim in the death of John Rollins at the Norman Veterans Center
Related Link: See the 2008 inspection report for the Clinton Veterans Center
Related Link: See the tort claim in the death of Jay Minter at the Claremore Veterans Center
Related Link: See the 2012 inspection report for the Claremore Veterans Center
"I'm wondering if we're just looking at the tip of the iceberg," Senator Simpson said, "when we look at the cases we know took place."
A former nurse at the Clinton center says there would definitely have been more reports of abuse, if not for fear of retaliation among both staff and residents.
"One of the veterans told me -- he's now deceased," Pamela Powell explained, "he said, 'this place is like Vietnam.' He said, 'I'm always having to look over my shoulder.'"
Sen. Simpson has heard similar complaints.
"I think we can trace that problem to 2003," said Simpson.
Sen. Simpson is referring to the year when ODVA convinced the Legislature to exempt the veterans centers from the state Nursing Home Care Act. The move freed ODVA from what its leadership felt were overlapping regulations, but which, critics say, had the effect freeing it from any meaningful oversight -- the veterans centers were no longer be subject to state Health Department inspections, but only the inspections of the federal Veterans Administration.
An interim study, conducted by Senator Simpson last fall, supported the contention that care at the centers suffered due to a loss of independent oversight, and that problems at the centers were minimized and, if possible, kept quiet. What's more, the V.A. inspections tended not to provide an accurate picture of the conditions at the centers, Simpson, says, since the administrators of the centers often knew in advance when they were going to happen.
"I would describe the V.A. inspection," Simpson told us, "and even one of the war veterans commissioners used these words -- as a dog and pony show."
Sen. Simpson, R-Ardmore, hopes to change that this year. Legislation he's introduced would again give the Health Department oversight of the veterans centers, and would make ODVA more accountable to the governor.
Related Link: Reform Bill SB 235
Related Link: Reform Bill SB 629
Related Link: Reform Bill SB 228
Related Link: Reform Bill SB 467
"Some checks and balances is what I call it," said Frances Minter.
Minter is a strong supporter of Simpson's proposed reforms. In losing her husband, she found a cause:
"I want to pay tribute to my husband," Minter stated, through tears. "I want him, through his death, to be able to help other friends and buddies in the service."