Inspector general report details past problems at Zablocki VA Medical Center inpatient unit

Investigators found problems in staffing, safety and protocol in late 2015 and last year in the mental health residential rehabilitation treatment program at the Zablocki Veterans Affairs Medical Center, according to a report released Thursday.

The VA Office of Inspector General made five recommendations to improve the facility, and Zablocki VA leaders say they have carried out almost all the required changes.

"I do believe that program is meaningfully and significantly more safe and secure than it was," said Daniel Zomchek, who became the Zablocki medical center director in June 2016.

The report was triggered after the inspector general was notified of problems at the Zablocki domiciliary facility by Democratic U.S. Sen. Tammy Baldwin. Beginning in 2014, her office received complaints from whistleblowers. Republican U.S. Sen. Ron Johnson raised concerns last year.

The Zablocki medical center was rocked Nov. 9, 2015, when Cole Schuler, a 26-year-old former U.S. Army Ranger from the Fox River Valley, died of a heroin overdose 11 days after entering the inpatient drug rehab unit. Schuler was found slumped under his desk in his bedroom. 

Schuler, referred to as Patient 1 in the report, had been complaining of sickness for several days after checking in to the unit. On the morning of Nov. 9, he told a nurse that he was "feeling achy and had a sore throat," the report says. He was placed on bed rest and did not attend "his designated medication dispensing time in the early evening."

"Five and a half hours later, his roommate found him unresponsive in his room," the report says. The Milwaukee County medical examiner listed his cause of death as acute mixed drug toxicity.

ARCHIVES:Problems found at Zablocki VA weeks before overdose death

VA investigators found safety and security issues during onsite visits in October 2015 and August 2016. They determined staff did not consistently conduct or document rounds, maintain a presence in the units or conduct "regular and random contraband checks."

The units were also found to be short staffed. There were also problems with video cameras.

Zomchek said additional staff has been hired, security has been added and 70 additional cameras have been placed in public areas.

"Did we need to tighten up on safety and security? Absolutely," Zomchek said. "I believe that in my heart we have significantly and meaningfully improved safety and security."

Baldwin said she has worked over the last three years with whistleblowers and later the Schuler family "to raise concerns about the Zablocki VA" and call on the VA to investigate.

"For me, Cole’s tragic death sadly highlights the fact that the VA did not take the actions necessary to address these problems," Baldwin said in a statement. "The Inspector General report makes clear that the facilities at Zablocki lacked competent management, were inadequately staffed and were not safe and secure environments for veterans.