Patient Safety At Center Of Montana VA Shakeup

Patient Safety

One whistleblower says patient safety in the operating room is at the center of the shakeup going on within the wall of Fort Harrison VA in Montana.

In 2014, Associate Chief of Inpatient Care Dianne Scotten just started working for VA and was responsible for ensuring operating room errors are prevented.


Shortly after starting, Scotten filed a safety report about clinicians failing to perform a surgical towel count after surgeries. Accounting for towels and other items following a surgery is an important practice to prevent incorrectly leaving foreign object in a patient’s body.

After the report was filed, an investigation led to material changes to operating room staff procedures. This makes sense.

What does not make sense is the retaliation that transpired later. Scotten was not prepared for the avalanche of harassment that would follow, apparently at the hands of Associate Director for Patient Care Services Norlynn Nelson.

According to Scotten, after filing the patient safety report, Nelson apparently reassigned Scotten, cut off communication, and shut her out of meetings. She also prevented Scotten’s participation in patient safety meetings.

But according to Nelson’s statements to Flathead Beacon:

Scotten was underperforming in her job and had alienated the nurse managers under her by talking about them to other staff, Nelson testified. That upset an already tense situation among operating room staff members who had been in conflict with one another before Scotten’s arrival, Nelson said.

One nurse manager was upset that Scotten had gone outside their department with her report instead of speaking to the nurse manager first. But Nelson said she did not retaliate against Scotten for filing the report.

“I can see why she did. Good on her,” Nelson said.

Instead, Scotten was reassigned away from the operating room to give her a better chance to learn the VA system and excel in her job, Nelson said.

Who should we believe, Nelson or Scotten? Given how impossible it is to get fired for doing bad things at VA, does it really make sense that Scotten could have been underperforming at anything within the first month of taking over such a position?

That would either mean VA is piss poor at hiring a senior leader within the agency’s health care system or Nelson is totally lying. Which do you think?

If Nelson is lying, and I bet that she is based on the lack of logic within her own statements, I hope Scotten goes after her for defamation.

After being reassigned, Scotten filed a grievance because of the retaliation, but soon resign / retire John Ginnity was failed to timely respond to her grievance. As a result of the delay, Scotten was forced to resign her position.

RELATED: Montana VA Director Resigns Over Broken System

This explains a little as to what I wrote about last week with Ginnity resigning. Rumor has it VISN 19 leadership, the mothership responsible for Fort Harrison VA, is at the center of many of the problems including cover-ups of wrongdoing and endangerment of patient lives.

The Scotten story is but one example of negligent leadership at the facility where lives are endangered without adequate investigation. I think it is high time Secretary Bob McDonald take on the corrupt staff within VISN 19 before more veterans died.

The big scheme within VA under this Administration was to keep a lid on the scope of the wait list scandal and resultant deaths by hamstringing the OMI investigation at Phoenix and elsewhere. The trick used by VA was to bounce the investigators back and forth during different reviews until the matter falls out of vogue with the press.

Once no one is watching, VA will finally conclude its investigation into corrupt practices and the wait list – likely resulting in a watered down version of the truth that ultimately concludes VA fixed all problems, amen.

What is going on at Fort Harrison VA?


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  1. I can tell you as a former employee of VA Montana the upper management was corrupt and if you didn’t “go along with them” you were deemed a “trouble maker” and denied promotion. My husband and I both worked there, him a veteran himself, and neither of us were promoted despite qualifications being met. When we received our Nurse Practitioner we were told that we need not apply to the VA that they did not hire new graduates yet just before we left they did just that. Makes you wonder.

    1. They call that a team player, you were not a team player. You have to prove to them that you can be a lier or a cheat. They don’t want honest people anymore. Until people a lot of people go to jail or be fired nothing will change.

      An employee was caught robbing someone and the AFGE, got them reinstated, why because they pointed out that there were other employees that had trouble with the law and they were not fired. Go figure !

      1. It is truly a shame because our veterans deserve good quality health care and there are a lot of good people who work there who really care but they are either kept in the lowest positions our made so miserable they leave like my husband and myself

      2. I am also a former VA employee and trained in all positions in medical administration. Worked about 22 year’s with them as an administration assistant

        Said something about an employees job performance and that employee. Once they found my record’s and I became100 percent disabled and was given a medical retirement

        The employee whom I said something about her job performance. Was hired as lead administrator and she used her position to retalate against me

        She reported to the VA disruptive committee that I would come into the new cboc at least twice a month and become disruptive

        As you know as a VA employees we were required to complete a report of contact if something negative happened. To cover our butts

        This employee was able to get the chief of staff chairman of the disruptive committee to punish me for being disruptive. She was not required to provide proof that this actually happened

        The chief of staff admits they had no proof. But stated those were the facts. How can something be fact and you have nothing to prove it as fact

        People like these are able to hurt veteran’s and then cover it up. Sad thing even with proof that they admitted they had no proof. Bob McDonald’s office did nothing and no one else seem to care

        The VA has made me very bitter. Knowing they don’t care if employees are hurting veteran’s or even kill them. They say 22 veteran’s committed suicide each day. I believe they the VA

        Has given these veteran’s no treatment or they Fed them so much medication. They killed themselves. !

        Sad in deed. God will sort them out. Seems no one else cares. How many veterans die. The more the better. No sweat off their backs. Just say next

  2. Diane Scotten was telling the truth. the dictatorship of va montana has been atrocious. the retention has been awful. ask how many nurses have left in the last year or 2? how about between 50-60? what does that say?? the woman at the helm of it all is a vicious and mean woman who deserves to have her feet yanked off the pedestal she has so enjoyed. she lies, cheats and trains the others all around her to do the same and if they don’t she either fires them, or makes them want to quit. her managers all do the same.

    1. Veterans. Have been the victims of management like this person your speaking about. !

      And as you say the staff too. Who wants to work for someone who thinks they are a God. !

      McDonald and other high officials know this is a major problem and they have no clue how to fix it. !

      These employees ? off the good employees and use the tax payer dollar’s to pay off the bad one’s with yearly bonous ? !

      Demands. Have to be made. ! IF. You just talk and have no bite. !

      They will treat you special and then laugh at you once you turn your back. !

      That song. They ? in your face. The back stabbers. !

  3. Question to all:

    How would y’all like to be sitting in one room, behind closed doors, and upon leaving find out another person in another room, right next door, a RN, was either;
    1.) listening in or
    2.) reading what the doctor was typing about you?
    As you exited the doctors office. Your asked pertinent questions as to what just took place in the doctors office! Out in the hallway! Open to anyone who wants to listen.
    This just happened to my wife and I at a VAMC, small clinic, here in Central Florida!

    I don’t know what the hell is taking place here. Yet, I do believe my rights were just violated!

    Any suggestions?!

    1. Hey Elf,

      Number one — all exams are recorded at the VA. No matter what anyone tells you that is a fact.

      Number two — knowing what you do about the VA Health Care System why are you still trusting them with your health?

      1. Also Elf,

        A good article on the Orlando shooter.

        “Omar Mateen, Wackenhut, and the CIA Mateen’s employer serves as a front for the CIA
        Kurt Nimmo – June 13, 2016”


        going beyond that article

        Some of the security work the company the shooter worked for also does nuke plant security.

        “New LANL Security Contractor And New Lessons Learned Arrive On The Hill”

        Submitted by Carol A. Clark
        on February 4, 2016″


      2. @Seymore Klearly

        One thing I’ve been noticing is the POTUS, Hillary and a few other (traitors) up in Washington are trying to put the blame squarely on the FBI. Especially over the way Mateen “acquired his weapons”!

        Also, the “Gun Shop Owner, who’s been taking LOTS of heat, came out today and stated; “…everything was done ‘by the book’!”
        I believe if Obama continues to push the FBI, the “desired effect” he’s looking for, might not be so “desirable”!
        What do you think?


        On the local “piss-ant” vamc down here. It’s all I can get and use.
        I’ve tried to get outside healthcare. Been told to use VA! Just like some others on here.

        As far as recording anything. Florida is a “two party” state. Everyone has to give permission!
        Talked to my Congressional Aid today. He said they violated the rules and regulations set down by law!
        Hope to get some justice! At least my wife and I are giving it a shot!
        That’s all anyone can do, right?!

      3. Elf,

        In regards to Obama he pretty much has control of the major media so no matter what, he gets to shape the discussion through them.

        In regards to the VAMC just like if they change the rules where nurse practitioners get to preform the work of Doctors. Nurse practitioners in all VAMCs will be entitled to perform the work of doctors regardless of any state laws against it. Same thing with the VA and recording all exams they do it regardless of any state laws.

    2. Put it in writing to the Patient Advocate. They may not do anything, but it’s a place to start, and will make them look stupid if you force the issue and find out later nothing was done.
      I am seeing this violation of patient privacy at the VA every time I go there. In the Ortho clinic, for some reason they have the Patient intake screening out in the waiting area. They put up a flimsy divider between one of the waiting room chairs and the rest of the waiting area…as if sound will not travel over the divider. Anything said during the intake screening can be easily heard by anyone else in the waiting room, even if they are speaking softly.
      When you go back into the clinic area, there is plenty of open spaces to do intakes back there, but for some stupid reason they do it in the waiting room.
      Same with the primary care clinic. Their exam rooms are within a few feet of the waiting area, and the primary care providers leave the doors open so anyone sitting in the waiting area can hear anything said during the exam.
      I recall reading an article here or somewhere that contained a link to reports from VA hospitals across the country on HIPAA violations. I found it. Do a search using HIPAA violations by VA. You will find an NPR news article on it, and within The article is a utility called HIPAA Helper where you can search for HIPAA violations by VA hospital. My VA shows 449 violations alone. The article was suggesting they were trying to get the VA to report violations no matter how small, so they could improve. I have commented here before on those reports, and what was found at my VA. Most were minor violations, but some were of mailing or facing veterans medical records to a bank or other hospital to people who should not be seeing it.
      If you write a letter to the Patient Advocate, you can wait a week, then submit a FOIA request for that hospitals HIPAA violation reporting log and see whether they reported it.
      In my own battle with the VA, I got the Congressional response yesterday. Someone lit a fire under their ass because they responded to every question I had. Some answers raised more questions, but the Congressman’s office asked me to hold off on responding until all of the responses came back, including from McDonald’s office.
      I did not know Healthnet has an entire Patient Greivance section, but I do now. I also did not know Healthnet is considered a Secondary payer on all Veterans Choice appointments, but I do now. Its no wonder veterans are getting billed for their Choice appointments. The response said the bill for my Choice appointment was incorrectly sent to Ft. Harrison, MT VA. It does not say whether the VA contacted the provider to correct that mistake.
      I am still waiting to receive my FOIA request that was mailed out last week. It included any reports on their Patient Contact log which is an internal VA reporting system used to report to upper management any contact with a patient, such as with a Patient Advocate.
      It should be interesting.

  4. The VA is a rogue agency. Of course they retaliated. As an organization they react precisely like an untreated PTSD patient who hasnt slept for three days. They act like this any time a perception of personal slight occurs and their wrath is not limited to just patients and co workers. Look at the moron who runs the brotherhood – openly challenging to personal combat (“…I will kick his ass”) the cabinet level official responsible for maintaining order and discipline. In effect their own leader gave The President the middle finger by saying this to Bob.

    Given this fact, why would anything shock the public when they all behave is way?

    Nobody is insulated from the Senior Staff (SS) at VA.

    1. @Redturtle984

      That’s a perfect acronym for VA upper management and all the other asswipes – “SS”
      They are definitely a “storm trooper” entity!
      But, remember what happened to them – Complete destruction!

  5. The VA acts like a feudal system of government. The King, (McDoanld), princes, dukes , marquees, earls, counts, viscounts, barons, knight-lords and down to the peasants (the union crowd) all have land (areas of responsibility – their fiefdom). They then protect that fiefdom against attack by neighboring fiefdoms, down line nobility or peasants, visitors to the Kingdom, or enemies of the King.

    The King’s treasury is misspent and looted regularly by the nobility to the detriment of all visitors to the Kingdom.

    You now understand how the VA operates.

      1. I agree with namnibor, Dan F! Extremely great anology of the VA!
        Only, I would add the top KING – the Commander in Chief Obama!

    1. You are right, but many of them should not hold a position above that of the Piss Boy. Think History of the World by Mel Brooks.

  6. What do you expect? The HR chief ran to Montana from Phoenix where he participated in proven retaliation against whistleblowers and then was found to have given untruthful testimony related to it before MSPB. Business as usual.

  7. I think it is tough to effect change in a small town where everyone is used to doing it one way and they don’t like ‘troublemakers’.

    1. Actually, the VA is a “System”, and there lies one huge problem with the VA, the lack of Standardization in the System.
      It should not matter one bit whether a Vet goes to a VAMC in Montana or Alaska or Florida…that very LACK of Standardization keeps the chaos pot stirred in the VA cesspool.
      Why try to project the ‘blame’ on the ‘Local Montana Folk’????? Damn! Those crocodile tears must be a pain in ass to clean up all the time.

  8. Retalation ? Retalation? That’s the name of the game. !

    They not only do this to their employees. They do it to past employees who are veterans. !

    Some employees tell it like it is !

    As were all know. This us standard practice. !

    You know they will punish anyone. Veterans are another target if they speak out. !

    They don’t care. !

    The God syndrome gotton out of control and it has to stop. !

    Since when is doing the right thing. (Wrong) !

    Active criminals. !

    and getting away with it and Americans wonder what the hell is going on.

    When they see people being treated like shit. They future it’s the norm and they start doing it.

  9. Honestly, at this point, I am finding it very hard to tell the male rats from the female rats at the VA. No matter whomever may be telling a ‘version’ of the ‘truth’ here, Veterans are the end of the gravity slide of the VA Poop Shoot. These VA employees will clamor and stab each other in backs and vets along the way to ensure their cookie jar keeps runneth over in the VA Land of Milk & Honey. BasTurds. Bad mood today and get off my lawn!

    1. @namnibor
      I just ran into q friend who I’ve not seen in a couple of years.
      He goes online to many sites quite a bit. He informed me there are alot of veterans AND taxpayers out there really pissed off!

      Think about it. 600,000+/- show up at “Rolling Thunder!” on Memorial Day this year!
      Tens of thousands of veterans AND taxpayers are showing up at the MANY Trump rallys around the U.S.
      He just had a rally in Virginia this past friday. Where something like 6,000 +/- showed up on less than a 24 hour notice.
      Then he came to Tampa Florida on Saturday. I don’t know how many showed for this one. But, I’ll bet it was a large crowd!
      Tonight he’s speaking on his “favorite subject” – Hillary Clinton on some show!
      I read this morning he’s going to change the “topic” from Hillary to the “insurgency of unvetted immigrants being allowed to come here!”
      Of course, he will have to speak about all the corruption, waste, fraud and abuse taking place within our government. Plus the attack on the “2nd Amendment” by Obama, Hillary and others!

      “rant over”, I’ve had a VERY BAD DAY!
      Seems the VA put me in a real bad mood this morning!

  10. Let’s see Dianne Scotten was hired in March or April 2014 as the Associate Chief of Inpatient Care. Within 30 days on the job she filed a patient Safety Report outside of the Chain of Command. Which was filed sometime in April 2014.

    Mr. John F. Ginnity, was named acting director in June 2014, was removed from that position after exceeding the 120-day cap on interim appointments.

    His first day as permanent director came less than a month later, and only weeks after the VA announced it was temporarily closing its inpatient acute care mental health unit on the Fort Harrison campus because of “chronic workforce shortages.”

    Although Dianne Scotten claimed in her whistleblower complaint that she was forced to quite the Associate Chief of Inpatient Care position at the VA due to retaliation. Google show that at least back in November 2014 she was working as the Director of the larger newly built and opened Montana Mental Health Nursing Care Center. Which also provides inpatient Mental Health Acute Care for Veterans.

    Gee can’t image why there was a staffing shortage.

    At least Dianne Scotten’s golden parachute landed her in a nice soft feathery nest. Oh, and to top it off the VA then decided to permanently close their acute care mental health unit at Fort Harrison due to Veterans preferring to receive care closer to home.

    Also with the AFGE there to help this poor woman steps up to help with a lawsuit claiming she was forced out of her job December even thought she was working her other job 180 miles away at the time. That means a possible great big additional payday for Scotten just by smearing the name of Mr. Ginnity.

    Wonder what kind of drug trails they are using on Veterans at her new location. Not likely to be limited by any of those ethical problems like at Tomah’s inpatient Acute Care Mental Health Unit. Candy Land and the Candy Man. In Montana they already have laws allow nurses to do the work of Doctors.

    1. @Seymore Klearly

      I think we veterans are never going to know the full scope of what’s occuring within the VA!
      From POTUS on down, they say one thing and do the apposite.
      “Grand Standing” and “Photo Ops” are all citizens, (taxpayers), and veterans receive!

      Like the National Commander of the VFW stated,
      “Don’t Insult Vets Intelligence!”
      (3 June, 2016)!

      1. I agree Elf

        But there is one thing that we definitely know is true about VA Health Care and that is it is getting Deadlier every day.

    2. Got to wonder if they have TeleMed at where Dianne Scotten is the Director. After all it would certainly be a great opportunity for Dr. Houlihan to further his cocktail research.

      With an ethically and morally challenged Director running the facility, no more of that nasty VA Over Sight that might blowup if some none corrupted Senator starts looking into what is going on there, and no real Doctors to question what is going on with your Lab Rats.

      Looks like Montana has a quite extensive Tele-Med System in the field of Mental Health.

      Truly a very questionable place.

    3. A little more about that poor abused Dianne Scotten who claimed she was forced to leave the VA due to retaliation for filing a complaint. Who also tried for a big payday lawsuit by smearing the name of Mr. Ginnity.

      Her Linkedin profiles show that while she was working her position at the VA she was also employed as

      Chief Clinical Officer/Executive Director of SNC
      central montana medical center
      March 2004 – Present (12 years 4 months)



      Her other job that dates back at least to November 2014 is as the before she was forced to quit the VA in December of 2014 due to retaliation she claims.

      The Director of the Montana Mental Health Nursing Care Center



      Oh and yes they do use Tele-Med at the Montana Mental Health Nursing Care Center!!!

  11. I believe Scotten!

    I believe she did her job.

    I believe there’s a large problem within the VA NOT abiding the rules and regulations!

    I believe the many cover-ups goes much deeper than what veterans are made to believe!

    I believe there should be an independent law enforcement agency going in and arresting those responsible for any and all egregious acts committed against veterans!

    The corruption permeating within VA starts with potus and has worked its way down the ranks!

    I believe it will only stop when someone with balls will step in and take care of business!


    Here’s a Utube video explaining the corruption within the White House and one of those running for POTUS!
    It was out yesterday, 12 June 2016.
    title to Google;

    “Here Comes Da Judge & Out Comes The Clinton’s Skeletons…(A House Full)”

    W/Judge Jeanine Pirro

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