McGuire Veterans Medical Center endangers forty additional veterans. Security, safety, and needed emergency services are being jeopardized.

With the completion of the new forty-bed wing at Sitter and Barfoot Veterans Care Center, it brings the total to over two hundred employees and veterans at risk.

Sitter and Barfoot is a long-term facility for veterans honorably discharged from active service that need rehabilitation or long-term skilled nursing care. It is a nursing home.

Sitter and Barfoot is situated on the property of McGuire Veterans Hospital, yet security and emergency response falls to the Richmond City Police, Richmond Fire Department, and outside or city ambulance service.

In what could only be attributed to a cost-saving effort, the most direct route to Sitter and Barfoot is through a gate that is closed and locked at dark, and twenty-four hours a day on weekends, and holidays. The locked gate impedes all emergency vehicles; ambulance, fire, and police. This mistake causes emergency responders to take a more circuitous route through McGuire’s main entrance, putting over two hundred of the most vulnerable veterans and state employees at risk. Veterans that suffer from dementia and Alzheimer’s; many are unable to walk, and all suffer from medical conditions requiring skilled nursing care.

It is a fact that in an emergency, every second counts. The closing and locking the gate slows the response time for all emergency vehicles responding to life and death conditions—delays with dire consequences. Life-threatening delays.

For the safety, security, and well-being of employees and aging veterans, it is critical that Sitter and Barfoot be patrolled and the gate open 24/7.




Am I a statistic or a “harmless error” of the Veterans Administration Health Care System?

The diagnosis was that I needed a triple bypass and an evaluation of my heart valve.

My heart surgery was put on the fast track and scheduled for late March, 2011. The result was a “successful” quadruple bypass and a bovine aortic valve replacement.

Beginning in mid-July of 2011, I started experiencing lower back pain on the left side. It became increasing more severe. I finally decided to go to the emergency room at McGuire Veterans Hospital located here in Richmond, Virginia. The ER doctor examined me, and her suspicion was an intestinal issue. I was treated and released.


I was diagnosed six weeks later with an abscess between T-8 and T-9 vertebrae caused by the MRSA (Methicillin-resistant Staphylococcus aureus) bacteria that colonized in my spine. The abscess was putting pressure on the spinal nerves and needed to be removed. McGuire Veterans Medical Center performed a laminectomy on my spine, and I have not walked since the surgery.

Below is an excerpt from my progress notes dated 09/21/2011 on page 630:

Epidural abscess & Back pain: The source is probably the bovine valve which was replaced on March [30th, 2011] since there is no other obvious cause of abscess in this otherwise healthy gentleman. No history of pneumonias or admissions for sepsis. No hx of IV drug use.

The progress note points the smoking gun back towards the “bovine valve” that was implanted at McGuire Veterans Medical Center five months earlier.


The Veterans Administration placed me in a veterans’ nursing home as a paraplegic, cast aside like waste, destined to die a slow and heartbreaking death—alone.





There is no mechanism in place for the Department of Veteran Services to perform operational oversight of Sitter and Barfoot Veterans Care Center, according to the Care Center’s administrator.

Sitter and Barfoot is a long-term care facility that provides rehabilitation services and medical care and comfort to as many as 160 veterans. It has two units, each with sixty private rooms. In addition, there is a specialized Alzheimer’s/dementia wing with forty rooms.


I requested a copy of an inspection done by the Department of Veteran Services. Instead, I was shown the review done by the Department of Veterans Affairs, the federal agency. When questioned, the administrator stated that the Virginia Department of Veteran Services does not inspect the operation of Sitter Barfoot. Further, the administrator said that Sitter and Barfoot is checked twice a year by two separate agencies: one federal and one state.

The two annual inspections, done by the Virginia Department of Health and the Department of Veterans Affairs, are done to evaluate the operation and care given to the most deserving of our aging population.

The Department of Health and Department of Veterans Affairs inspections cover the operation of the Care Center and typically last three to four days. Each department operates independently and comes at different times of the year.

The Department of Health evaluates the overall care delivered to those 160 veterans: quality of care, medical records, privacy, personnel practices; rehabilitation, food preparation, staffing, resident complaints, medications and more. Towards the end of the inspection process, a meeting is scheduled. The administrator and the director of nursing convene with the survey team to review the deficiencies found and draw up a corrective action plan.

Sitter and Barfoot received the highest grade possible in the 2014 survey.

After an interview with a health department surveyor, the health department failed to address four of my concerns:

• Medication errors
• Short staffing
• Ignoring communications
• Lack of dignity and respect

The health department showed little interest in my issues. Complaints from nursing home residents are considered unreliable and often ignored.

It begs to question the effectiveness of such an assessment and the trustworthiness of the Department of Health.

The Department of Health acknowledges a 12 to 15 month wait time to investigate complaints. I now have to wait again to get resolution. Residents in a nursing home would be fortunate to have that many months left.

The cleanliness of Sitter and Barfoot affects those doing the survey and accounts for the disparity between fiction and reality. Cleanliness covers many evils. Overall appearance diverts attention and unduly influences the outcome of the inspection.

The Health Department and Sitter and Barfoot are both state agencies. I question the reliability of one state agency evaluating the performance of another. Corruption, complacency, and a lack of transparency obscure objectivity in government self-appraisals. It is unlikely that a state agency tarnishes another agency’s operation; particularly one with such high and honorable intentions as caring for aging veterans.

The Department of Veterans Services needs more accountability in the delivery of care to deserving veterans.

Accountability does not stop with the administrator. The administrator has self-interests and financial demands to protect, as well as job security for the employees that have shown allegiance. The administrator and staff can hardly be expected to be objective. Government agencies have demonstrated that they do whatever is necessary to protect their province.

The Department of Veterans Services needs to be held accountable and responsive to the needs of all veterans it serves. It is mandatory that the Department of Veterans Services be pro-active and aggressive in ferreting out problems. Not just a self-serving propaganda arm for the Commonwealth.

Accountability at the top will cure the ills of Sitter and Barfoot and the Department of Veterans Services—and accountability with consequences must filter down to all levels.





In April of 2013, I experienced repeated abuses in the restricted parking at the McGuire VA Hospital. The handicapped crosswalks were blocked with automobiles illegally occupying those designated areas. I went to the police office and lodged a formal complaint. In this instance, the officer that responded to my complaint refused to ticket the offending vehicle.

I wrote a letter to the interim director, David Budinger. His response, in writing, was that because of the shortage of parking spaces the Veterans Police had adopted a system of “compliance enforcement.” That term was never explained to me, but clearly it meant no enforcement at all.

The conditions continued until April of 2014. I wrote a second letter to the new Director of the hospital, John Brandecker:

April 7, 2014

John Brandecker,
Director, Hunter Holmes McGuire VAMC
1201 Broad Rock Boulevard
Richmond, Va. 23249

Mr. Brandecker:

You are just one more failure in an unresponsive Department of Veterans Affairs.

You, as director, should be ashamed to have under your leadership, a law enforcement department that discriminates against a disabled veteran and fails to enforce traffic laws.

I have dedicated my time, professionalism, and intellect to serve the veterans and family members at McGuire Veterans Medical Center. Under your leadership, I have been unnecessarily inconvenienced and discriminated against by the Department of Veterans Affairs Police Department. The parking problem exists because of poor management and planning. That does not exempt you from the mandated laws and the requirements associated with enforcement. The Department of Veterans affairs chose to discriminate against the disabled as the avenue of least resistance. You have allowed this discriminatory practice to establish itself, and it has become the norm. To subject those that devote their energies and resources to assist veterans and family members to such abuse and ridicule is contemptible.


Robert E. Carr
cc: Mrs. Michelle Obama
Honorable Tim Kaine
Office of the Inspector General

This letter apparently hit a nerve.

My heated verbal encounter with the Police Chief and his pathetic defense of the “compliance enforcement” doctrine did not resonate well with the Director. He immediately changed the policy and placed orange cones in the wheelchair crosswalks.

The following is the net result.


Even police chiefs can be stupid!

I thank the Director, John Brandecker, for standing firm and in support of veterans that are wheelchair bound.





Another door closes.

I requested a physical therapy consult through my outpatient nurse at McGuire VA Hospital.


What I was looking for was a comprehensive physical therapy regimen to improve my lower body strength so that I may regain more independence.

The consult was set up with Laurel Hackett in the physical rehab department at McGuire.

Immediately I was aware of her reluctance in accepting my objectives as realistic. I received no encouragement or support. She just gave me reasons why my best opportunity for success was immediately after a spinal cord injury; not 24 months later. No one explained that to me at the time of the injury or in the recovery process.

The second visit I actually got into the standing machine. Laurel took measurements and monitored my blood pressure while increasing the vertical positioning. The session was punctuated with interruptions, moving of equipment, and concern for a patient who had taken his power wheelchair on a tour of the hospital.

Laurel had requested that I provide her with a list of the exercise equipment available to me at the nursing home, Sitter and Barfoot Veterans Care Center. On the third trip, I gave her the list.


Laurel began making inquiries as to why I hadn’t approached the therapy department at the nursing home for my physical therapy needs. I explained that there was a communication issue, lack of credibility and void of any enthusiasm or encouragement. She then began to distance herself more. It was clear that she was developing a conversational exit strategy.

Laurel mentioned the fact that perhaps we were “re-inventing the wheel” and that I would be better served talking to a therapist at the nursing home. She persisted to the point that I picked up my list of equipment, and I began to close our conversation.

She made several attempts to regain control of the conversation as I was leaving, but it seemed we were going nowhere.

I left McGuire VA Hospital more disappointed and discouraged as ever and returned to the nursing home.






The Veterans Affairs debacle has already slipped from the front page, having been replaced by yet another scandal.

Still, the VA leaves thousands of wounded, infirmed, and dying veterans to languish on long waiting lists.  Waiting for the fulfillment of yet another promise delayed.  The promise made to the young and the naïve enlistees years ago, and that has come back to disappoint them.

A nation’s anger, outrage, and memory do not extend beyond the lead story on TV or the front page.  We have an insatiable appetite for the crisis of the day, but are quick to forget yesterday’s news.

“Leave no man behind,” is the current mantra that excites and gets our swift and undivided attention; yet efforts to relieve the veterans’ health care crisis moves ever so slowly.

Mainstream media controls the focus of our thoughts.  Media deflects our attention from one newsworthy item to another, forcing us to prioritize. The extent of deceit and deception experienced by those veterans who, unquestionably, served with honor and distinction, may also be forgotten.

Already forgotten is our outrage about the girls of Chibok; our obligatory outrage shared with Richard Martinez has faded.  The shooting in Seattle has been forgotten, replaced today by another school shooting in Oregon.  That too will soon be replaced by yet another sensationalized senseless act.  Acts that have become part of the fabric that weaves seamlessly into entertainment.

As soon as we hear about another atrocious act we react much as a child reacts to the bell of the ice cream truck.  We run to embrace it.  Gather in as many of the tiny details as we can so that we may engage in the conversation.  To be the first to impress; to express an authoritative, uninformed opinion as to the cause, effect, and remedy for everything evil.

Congressional fact-finding committees are an exercise in redundancy.  Many have known about the failures in the VA for years.  It only took the effort and courage of one man to bring the truth to the forefront; Dr. Samuel Foote.

Now, veterans must remain involved, informed, and continue to put pressure on those that can make a difference and are committed to doing so.

Evidence is surfacing that the service organizations have done little more than further their own objectives, maintain the current condition, and resist or delay any change.

Watching the news, the Veterans Affairs scandal is no longer the top story.  It has been replaced by the health concerns of one service member with questionable credentials and, sadly, the deaths in an Oregon school while the VA continues to mismanage and delay the health care of thousands of veterans.

The VA has demonstrated that it is incapable of self-governing.  It will only change through unrelenting efforts of the veterans themselves and  independent, critical oversight.

It will change with the persistence of veterans willing to keep it from being just a faded memory.


To stay informed:





It is not only the Department of Veterans Affairs scheduling scandal. It is the overall level of incompetence, poor communication, poor medical staffing, and inadequate planning that plagues the entire VA system and jeopardizes veterans’ health.

It starts with the smarmy attitude of the administrative employee on the phone and continues to the unprofessional behavior of medical doctors; to outbreaks of Legionnaires disease in Pittsburgh; to an MRSA infection in Virginia. The VA is a failure at all levels and the study should encompass the entire operation, not just scheduling.




One concern is that the VA will overlook the ultimate goal; the delivery of quality and timely medical care. There must be the resources available.

At this point, the most viable option suggested is to force an increased demand onto the private sector. Is the private sector equipped for the influx of the needy veterans? Does anyone have an accurate number as to what the total number veterans needing health care from each facility might be? News reports have suggested that some on the waiting lists, and the waiting lists themselves, have just disappeared.

One approach would be to have the responsibility fall on the individual VA medical centers to triage and coordinate wait list reductions with the local hospitals and clinics that have known specialist and expertise.

The private sector providers must be willing to “volunteer” for the compensable service and must have the capacity to handle the additional workload. Oversight must be in place to insure that no one requiring medical care, be it a private patient or veteran, suffers a delay in treatment.

Each care provider would have to assume the responsibility, and that would play havoc with the insurance providers. Would the liability insurance providers even extend their coverage? Some veterans may feel that they will get better care and request the private sector. Does the private sector even want to become involved with the VA?

Will the private providers and physicians receive timely payments from the VA?

The VA has shown little ability and even less enthusiasm to do anything in a timely manner.






At least someone has the courage and a grasp on the magnitude of the problem.


To the Nation’s Veterans,

Over the course of the last few weeks, there has been a great deal of media coverage—rightly so—of the still-unfolding story coming out of the Department of Veterans Affairs regarding secret wait lists and other problems related to appointment scheduling at VA facilities. Last week, the Senate Committee on Veterans’ Affairs heard from Secretary Shinseki, representatives of some of the Veterans Service Organizations (VSOs), and others.

While a great deal of the media coverage of the hearing has focused on what Secretary Shinseki said, and didn’t say, much less has been seen of the testimony of the VSOs that testified. I wanted to take a brief moment to comment on that testimony.

First and foremost, I must recognize and commend the American Legion, National Commander Dan Dellinger, and the American Legion team for taking a principled stand, before the hearing and during it, and calling for leadership change at the VA. It is clear that the Legion has been listening to its membership about the challenges they face in gaining access to care, and has reached the conclusion that “enough is enough” and the status quo is indefensible. The Legion’s membership has much to be proud of with the organization they support.

Regrettably, the Legion was alone among the VSOs that testified in taking such a stand. It became clear at the hearing that most of the other VSOs attending appear to be more interested in defending the status quo within VA, protecting their relationships within the agency, and securing their access to the Secretary and his inner circle. But to what end? What use is their access to senior VA staff, up to and including the Secretary, if they do not use their unprecedented access to a Cabinet Secretary to secure timely access to care for their membership? What hope is there for change within the VA if those closest to the agency don’t use that proximity for the good of veterans across our country?

I believe the national and local commanders of every VSO have the interests of their members at heart, and take seriously their commitment to their members and their organization. Unfortunately, I no longer believe that to be the case within the Washington executive staff of the VSOs that testified. Last week’s hearing made it clear to me that the staff has ignored the constant VA problems expressed by their members and is more interested in their own livelihoods and Washington connections than they are to the needs of their own members.

I fear that change within the VA will not be possible unless and until these organizations also reconsider their role as well as the nature of their relationship with VA.


Richard Burr

United States Senator

Thank you Senator!






Representative Jeff Miller’s [1] bill, H.R. 4031, Department of Veterans’ Affairs Management Accountability Act of 2014: [2] Does it go far enough fast enough?

It is no secret that the Department of Veterans Affairs has serious problems. A crisis created throughout its hierarchy; a problem that creates delays in service resulting in needless anxiety, frustration, and frequently, death. [3]

The bill, ‘‘Department of Veterans Affairs Management Accountability Act of 2014,” will allow the Secretary of Veterans Affairs to remove members of the Senior Executive Service (SES) for performance.

Why not hold all management to the same accountability standard as the SES? Senior bureaucrats have stripped away any incentive for personal accountability and diminished responsibility throughout the organization. Those on the front lines of customer service should be as accountable as the seniors. It will do no good if senior management does not have the ability to dismiss unproductive or incompetent employees for performance shortfalls.


Civil service supervisors are unaware of the image their operation projects to the public. They no longer view their area of responsibility from the customer’s viewpoint, but instead, are busy responding to the whims of their supervisors and the occasional out of control grievance. Leadership is unaware of what happens on the front lines — under staffing, long lines, distracted, unresponsive, rude, and condescending employees. Employees are more focused on the timing of their next bathroom break or their cell phone vibrating than the client standing front of them. Supervisors have become too busy with a backlog of other priorities. Priorities designed to present ambiguous numbers and false positives. Priorities totally disconnected from the chaos that continues up-front, unabated. Priorities mandated by civil servants that are even more detached from the public’s perception of their operation.

H.R. 4031 makes no attempt to untie the hands of SES. SES is at the mercy of the lower chain of command with neither the ability nor the desire to make appropriate changes when necessary. There is little incentive to expend the energy or the resources to even meet, much less to exceed the veterans’ expectation. To change and insist on accountability throughout the Veterans Administration would require a fundamental transformation in the workforce and personnel practices. That is not likely to happen. The desirability of government employment would diminish. One of the well known perks of a government job is job security.

H.R. 4031is a step in the right direction and deserves support, but does little to untangle the mess created by mismanagement and poor planning that has plagued the Department of Veterans Affairs. H.R. 4031 will not be the silver bullet. Continued pressure on our representatives is imperative. The motivation of the department to self-govern has proven that they are more concerned about furthering their own interests rather than those of the veterans. Carefully concealing and shrugging off incompetence ensures a backlog of work and strengthens the employees’ grip on job security. Government can no longer protect the incompetent and unproductive civil servant. … Regardless of their position in the hierarchy.

“Despite the fact that multiple VA Inspector General reports have linked many VA patient care problems to widespread mismanagement within VA facilities, and GAO findings that VA bonus pay has no clear link to performance, the Department has consistently defended its celebration of senior executives who presided over these events, all the while giving them glowing performance reviews and cash bonuses of up to $63,000.00” [4]



[1] Rep. Jeff Miller, Chairman of the House Committee on Veterans’ Affairs