Page 9 DEPARTMENT OF THE ARMY OFFICE or THE CHIEF oF musponnmon 2221 name AVENUE FORT LEE. VIRGINIA 23001-2102 REPLY TO Am" 0F ATZF-CG 2 July 2014 MEMORANDUM FOR Commander, United States Army Medical Command, 2748 Worth Road. JBSA, Fort Sam Houston, Texas 78234-6000 SUBJECT: AR 15-6 Investigation (Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations) 1. On 9 June 2014, I was appointed an AR 15-6 Investigating Of?cer by the MEDCOM Commander to investigate allegations that Behavioral Health Providers (BHPs) at Evans Army Community Hospital (EACH), Fort Carson, Colorado failed to treat Soidiers undergoing administrative separation for misconduct with dignity and respect, and that they did not make impartial diagnoses or conclusions regarding mental status evaluations. Speci?cally, I was directed to investigate the following questions: a. Did MAJ Ifail to treat SSG lib?) Iwith dignity and respect on 23 April 2014 unprofessionally. with hostility. with a lack of empathy, or in a degrading manner)? (1) Did MAJnswer SSG questions about the purpose of the mental status evaluation? (2) Did MAJ blame SSGfor failing to report sooner? 3 Did MAJ use profanity in an inappropriate manner in this visit with SSG (4) ls there evidence that MAJ as biased. prejudiced. or otherwise in?uenced, coerced or pressured by leaders at Carson Medical Deartment Activa (MEDDAC) or leaders at Fort Carson to administratively clear SSG to undergo administrative separation for misconduct? cu ?nd no evidence of external pressure (see question 13(4), above), did interaction with SSG on 23 April 2014 reasonably create an impression that MAJ (W5) had already concluded that SSGwould be cleared for administrative separation? b. Did ILcsw. fail to treat Ilbti?ii Iwith dignity and respect on 2 May 2014 unprofessionally, with hostility, with a lack of empathy, or in a degrading manner)? Page 10 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations (1) Did say that SSGcommander ?is an asshole,? that he "has it out for you." and that ?you have a target on your back,? or words to that effect? (2) Did she inform his diagnosis on 2 May 2014? Did she say that the diagnosis really ?doesn?t matter,? or words to that effect? (We) (or his representativesJ?blls) I (We) have audio recordings or other evidence of the above encounters with MAJIibiiEl land libii?i If so, request a copy of the recordings or evidence. d. Does (We) orlibi?s) I have recordings or evidence of other instances of Behavioral Health providers at EACH or the Fort Carson Medical Department Activity (MEDDAC) allegedly failing to treat Soldiers with dignity and respect? if so, request a copy of the recordings or evidence. e. Are Behavioral Health providers at Carson MEDDAC biased or otherwise in?uenced, coerced or pressured by leaders at EACHIMEDDAC or leaders at Soldiers' units to administratively clear Soldiers to undergo administrative separation for misconduct? f. Were concerns about the quality of the behavioral health evaluation on 23 April 2014 raised to Carson MEDDAC leaders? It so, were appropriate and timely actions taken? 2. Investigation: a. IConsultant to TSG for was appointed as Assistant Investi sting Of?cer and Behavioral Health subject matter expert. LTC libiisl Deputy Staff Judge Advocate, MEDCOM was appointed as my legal adviser. b. From 10 - 15 June 2014, I conducted foundational work through review of policies. regulations, directives and other background information. I conducted daily conference calls with my investigation team. On 13 June 2014, I received a command brief via VTC from the EACH Commander, COL LeMaster, and an EACH Behavioral Health Services overview from the EACH Deputy Chief of Clinical Services, COL c. I traveled to Fort Carson, Colorado, and from 16 - 27 June 2014, conducted mission analysis, data collection, and witness interviews. I interviewed 24 witnesses, of which 20 were in-person, three TELECON (one witness on leave, two at DHHQ and one via \rrc (one w'tness at WRMC). I conducted follow up interviews with (bits) I (We) and one other witness. 0f the 24 witnesses, three were from SSG libiisi chain of command, one was SSG one was the Fort Carson Page 1 1 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations Ombudsman, two were from DHHQ. one from WRMC. two were patient advocates. and the remaining 14 were from within EACH. I also conducted site visits of EACH and EBHT3 facilities while at Fort Carson. d. I attempted to question 20 June 2014 at 1600 hours. After being read his rights warning, he invoked his right to counsel and signed a DA Form 3881. On 23 June 2014, MAJ defense counsel indicated that (would not provide a statement or testimony for my consideration. e. During interviews with patient advocates, and (19 8t 21 June 2014). I listened to and obtained copies of audio recordings collected by SSG dun?ng appointments with EACH Behavioral Health Providers. I also received an audio recording from (We) Iof another Soldier interacting with a EACH BHP in 2012 (SGT (We) . f. All Sworn Statements and audio recordings serve as exhibits to this investigation. All interviews were recorded 10 of the witness interviews and eight of the audio recordings provided byliblisi and Iwere forwarded for transcription. 3. Findings. a. Did MAJ (his) fail to treat see (We) IWith dignity and respect on 1bli5l 2014 with hostility, with a lack of empathy. or in a degrading manner)? Res - onse: Yes. I find that MAJ I?bllsi Ifailed to treat SSG ?with dignity and respect on 23 April 2014 unprofessionally, with hostility, with a lack of empathy, or in a degrading manner). (Exhibits: 5. 30. 34, 45, 46) Discussion: For the purposes of this investigation, I de?ned dignity and respect as: did MAJ treat SSGwith the professionalism expected of an Of?cer and Medical provider; and did he make SSGfeel as though he I mattered and his issues were important. (Exhibits: 5 34 45) I interviewed SSG and listened to an audio recording of SSG 23 n'l 2014 appointment with MAJ provided and liblisl (Exhibits: 5. 6. 34 con?rmed with two of MAJ superiors. LTC libilsl I that it is MAJvoioe on the recordin? . Exhibits: 36. 37) lalso reviewed a Memorandum for Record written by MAJ Ireoounting his recollection of the appointment. (Exhibit: 30) ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations 1) After considering all evidence colle ted concerning the 23 April 2014 2) 3) 4) (1) Did MAJ'ibi?El appointmen1;, i ?nd that MAJ (We) conduct during this appointment with SSGIibllEi was confrontational demeaning. and un rofessional. The evaluation began with SSGaskin MAJ (We) three direct questions. Rather than answer the questions. MAJ (We) responded in a confrontational tone. ?did on talk to CPTCompany Commander about that?? (Exhibit: 34) proceeded to interrupt SSG to correct him on details. for exam - Is ?no you didn?t go there. they took you there? when discussing SSG recent EACH emergency room visit. (Exhibit: 34) As MAJ -. ation progressed. the lack of rapport worsened to the point that SSG stated feel like you are calling me a liar? and ?you?re sitting here telling me that I am not feeling the way (i am feeling)?. (Exhibit: 34) Rather than taking the opportunity to calm SSG or address his increasing frustration within the evaluation. MAJ escalated the confrontation by saying in a condescending tone said for people that put down all of those 53 most of those people need to be in a hospital to be stabilized because right now you shouldn?t be walking around if that?s how bad you are doing?. (Exhibit: 34) MAJ xhibited an increasingly patronizing tone during the appointment. as evidenced by statements such as ?obviously it hasn?t helped. you are just doing as worse as you possibly could? and ?i could do a full assessment the way a is supposed to do but you are going to come - sitive for even/thing". (Exhibit: 34) This attitude and behavior led multi le occasions to feel the need to a ct ize for potentially disrespecting MAJ nd at one point asking MAJ (bills) if he needed to stand at attention. (Exhibit: 34) MAJ We) Ifailed to consider the impact of his conduct on the boundaries of the costar-patient relationship or upon the wellbeing of the patient. (Exhibit: 32) This was evident through SSGcomments to this investigator that he ?never felt so belittleo? in his life? (Exhibit: 5) and the discussions with both CP (W5) his Company Commander, (Exhibit: 34) and his therapist (bills) I on 24 April 2014 where SSG described the session as ?it?s one of those times where you are talking to somebody and no matter you say they think you are lying. (Exhibit: 34) nswer SSG questions about the purpose of the mental stems evaluation? Page 12 Page 13 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Hearth Providers - Findings and Recommendations Response: Yes, Mid answer SSG - ue 1 about the purpose of the mental status evaluation. However. MAJ answers were unclear and insuf?cient. Discussion: MAJ initially informed SSG that he was conducting a Fitness for Duty evaluation; he stated: ?is this person lit to continue in military service, are they tit to be chaptered out of the service, if they are not tit what do we do after that? We have to screen you for any type of illness, we have to screen you for traumatic brain injury which is told CPompany Commended i cant give them paperwork today because you have been referred to neurology and they have to quote unquote assess you. i am going to assess the portion and:' have already read your history since 2005". (Exhibit: 34) However. MAJdid not directly answer SSG three questions: who is directing this?, why are the directing this? and who does the report go Exhibit: 34) Rather, MAJ old SSG (W5) that he needed to ask CP (his Company Commander) those questions. In reference to SSG (bits) recent EACH 1- - my room visit precipitated by an alleged threat made by SSGIlbliEi IMAJused an analogy of a police response to a crime. (Exhibit: 34) ?Whenever something like that happens, you understand that the Anny is a very reactive place. What mean by reactive is that when something like this happens and there is a speck of a possibility that is possibly true. They like to get all around it and take care of it. So it?s like. . it me and a couple of buddies are walking down the street and you and a couple of buddies are walking down the street and you guys decide to jump us, rob us, or whatever the case may be. The cops get there. They put everybody in handcuffs until they ?gure out what is going on. They have to control the situation right now and then ?gure out later. That is what the Army does. They want to put their suits on everybody. Let?s figure out what is going on. They can tear it apart from there. it is a very reactive process that is kind of what is going on now. (Exhibit: 34) (2) Did MAJ We) blame failing to report sooner? Response: Yes, MAJ (We) blamed SSGfor failing to report soonen Discussion: MAuestioned SSG in a confrontational manner concerning why he failed to report his sooner. MAJ repeatedly 9-1. bli?l ATZF-CG Page 14 SUBJECT: AR 15-6 investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations focused on the fact that SSGhad not presented these earlier. MAJstated, 3) b) (3) Did MAJ "You can?t do that, you understand that. it?s unfair. it?s kind of like the thing. Back in 2011 your review was negative for and that was after your Now you are all of sudden telling people, that 's unfair for me, that?s unfair to you, and that?s unfair to every one of your providers who are taking care of you because youre not being inithiul. if you?re telling me that you're sicker than you really are, that 's not being truthful if you?re telling me you?re doing great because you need to go to selection and you don't care?: (Exhibits: 5, 34) SSG stated he felt MAJ (We) thought he was lying about his and that he felt MAJ (We) blamed him for not reporting his sooner. (Exhibits: 5, 34) This led to that: "i feel like you are calling me a liar" to which MAJ responded "i am not calling you a liar. What i am saying is that right now i understand you are going through a lot of stress. Ok. i understand that. But what i am trying to explain to you is that when locket your past history i dont see this much disability. i dont see you functioning this poorty as what you are reporting to me today. i don't see that. lim wondering why all of a sudden now?? and subsequent quotes of ?look at the timing, look at the timing.? (Exhibit: 34) MAJ ed 836 for not previously reporting but also implied that 886 only was see Ing care now due to ongoing disciplinary actions. Even if this were the case. several behavioral health professionals testi?ed that it is not uncommon for Soldiers to withhold behavioral health conditions until they are having problems and, aslibii?i I OTSG Staff noted, that ?it is not uncommon for the ?rst recognition to be some sort of problem in the workplace". (Exhibits: 9, 13, 25) use profanity in an inappropriate manner in this visit with 886 liblisi Yes. MAJ (We) ,did use profanity once in an manner in this visit with SSG Discussion: Accordin to $36 (W5) and the recording of the 23 April 2014 encounter, MAJ did use profanity once during the interview. (Exhibits: 5, 34) After discussions with multiple BHPs, find that there may be Page 15 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations times for the use of profanity in provideripatient interactions in order to establish and sustain the ?therapeutic alliance" or to "build rapport". (ExhibitsHowever. durin the 23 April 2014 appointment between MAJ {bills} and 886 MAJ use of profanity was inappropriate and unprofessional. Speci?cally, his statement in response to SSunestion ?Did you even review my fucking sieep study?? was did fucking review your sleep study and there is no need to cuss". (Exhibit: 34) This was unprofessional given the intonation and manner in which MAJ engaged SSG MAJ use of profanity escalated the confrontational tone of their conversation and detracted from the evaluation. Although SSG used profanity on more than ten occasions throughout the appointment Exhibit: 34), as a Major in the United States Army and a Medical Provider MAJ is held to a higher standard. Based on the context in which MAJ used the profanity, combined with the in?ection in his voice. MAJ use of profanity in this situation was inappropriate and unprofessional. (4) Is there evidence that MAJwas biased, prejudiced, or otherwise in?uenced. coerced or pressured by leaders at Carson Medical Dep 1th 1 Activity (MEDDAC) or leaders at Fort Carson to administratively clear undergo administrative separation for misconduct? Response: No, there is no evidence that MAJ was biased, prejudiced, or otherwise in?uenced, coerced or pressured by leaders at Carson Medical Department Activ? MEDDAC) or leaders at Fort Carson to administratively clear SSG lbi<5i to undergo administrative separation for misconduct. Discussion. There is no evidence to suggest that MAJ ver spoke with chain of comm other than to report to GP hat he would be unable to clear (Exhibits: 10, 22, 30. 34, 52) The preponderance of the evidence suggests that asked to evaluate 836 because of the increasing complexity of his case based on the recent alleged threats against the chain of command. This was not an uncommon practice per most of the providers (Exhibits: 7. 10, 13, 17. 20. 23). especially considering the increased command interest associated with the recent alleged threat that The Surgeon General's of?ce communicated to Fort Carson. (Exhibits(We) had already made clear that - . longer intended to wait until the 90 day mark as she instructed that she would be requesting ical testing. (Exhibit: 34) While she did not speci?cally request MAJIlbilEi ?llbil?i I did state that a Page 16 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations (5. did MAJ or would need to complete the evaluation because she was unable to interpret testing. (Exhibit: 7) i ?nd that there was urgency to complete an evaluation based on 856 alleged threats towards his chain of command and the lack of progression in care. However, I - - evidence to suggest that MAJ felt any pressure to clear administrative se aration. (Exhibits: 10, 11, 12, 22, 30) This is further evidenced by MAJ (We) conclusion initially to not clear 336 until after consultations other providers and the neurology evaluation. (Exhibits: 30, 34) If ?331(5) no evidence of external ressure (see question 1a(4), above), interaction with 386 on 23 April 2014 reasonably create an impression that MAJ had already concluded that 886 ould be cleared for administrative separation? Response: Yes, I ?nd that MAJinteraction with SSG lib?) Ion 23 April 2014 did reasonany create an impression that MAJ libii?ii Ihad already concluded that SSG would be cleared for administrative separation. Discussi MAJ (bits) communicated this information to SSG (We) At the beginning and the end of 23 April 2014 appointment. stated that he could not ole (We) and that he had already chain of comm I (Exhibit 34). This was veri?ed by CPT(Exlhibit: 34) Further. MAJ cleariy stated that he was ?going to wait on [$36 say. Then i am going to talk with needed ?to know their insight on this (886 case)". - ?33(5) acknowledged that MAJ (We) did speak without SSG (bits) MAJ "summed; and {bits} 9 what they statin that he (bite) I7 is gather collateral informat on. (Ex "lib": 7 Lastly i did not complete his medical record entry clearing SSG until? May 14. after the neurology evaluation was completed. (Exhibit: 64) All of these facts would indicate that MAJdid not conclude his determination on see ?tness for duty prior to the interview of 856 23 April 2014. a) However, MAJ onduct during the interview giv - pression he was biased and prejudiced to administratively clear SSG to undergo administrative separation for misconduct. Speci?cally, MAJ discussion about 886 (We) sychiatric history creates the impression that he does not believe 88 ?33(5) and implies that he may be seeking help of concerns over recent disciplinary issues. For example. MAJ - states: ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers - Findings and Recommendations "i understand what you are saying. But these are the kind of times when these things happen; this is where it hurts you. Because when you go through Path?nder and these Spec Ops schoois and you go through them. You have to get evaluated for that stu?. And if you tel! everyone down the road that you are ?ne in order to ?go to these schools than the record that i have and the oniy thing i have to go off of is a past of you being okay and then now there is incident January or December whenever that happened and you show up at EBH in January now alt of these probiems since then. looked at the timetine i don ?t know how many times. know you are going through this stu?' but part of my assessment has to be your past and i need to clarify some things with you before we move on?. (Exhibit: 34) b) Further his comment about his exam "i couid do a full assessment the way a is supposed to but you are going to come up positive for everything? (Exhibit: 34) indicates that he is not going to conduct an evaluation as he has already come to a conclusion. c) These statements and the manner and tone of the inte in SS (We) with the impression that the clinical interview with MAJ (We) was biased and that - repeatedly accused of making false statements. (Exhibit: 34) if MAJ had completed an ob'ective interview. the resuits may have been supported; however. MAJWE) conduct during the interview places the evaluation in question. b. Did (We) Lcsw. fall to treat see (We) with dign ty and respect on (bi(6i 2014 unprofessiona y, with hostility, with a lack of empathy. or in a degrading manner)? Res o, ?nd that there is insuf?cient evidence to show that (We) LCSW. failed to treat SSGIibiiEi with dignity and respect on 2 May 2014 unprofessionally, with hostility, with a lack o? em ath or in a degrading manner). However, the evidence shows (We) ?did act unprofessionally by inappropriately criticizing $86 (We) chain of command, insulting his battalion commander. using profanity. and providing advice outside the scope of her expertise during the 2 May 2014 appointment. Discussion: For the urposes of this investigation, I de?ned dignity and respect treat SSG ith the professionalism expected of a Medical provider and DA civilian employee; and did she make him feel as thou he mattered and his issues were important. (Exhibits: 45. 84) libiisi I Page 17 Page 18 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations con?rmed that she was the provider on the 2 May 2014 recording. (Exhibits: 7, 31, 34, 39) I also i land reviewed a Memorandum for Record written by (We) concernin of the appointment. (Exhibits: 7, 31. 34. 39) I?ndth. ugh (his) conduct during her 2 Ma 14 appointment with SSG. ?53 iwas unprofessional. she treated SSG with dignity and respect. 1) de?niter demonstrated empathy for SSG Her intent seems sincere. albeit misguided. Exhibits: 7, 34) She made several dis are in commentslabout SSG Battalion Commander, LTC I comments were not only unprofessional but served to further alienate SSGIlbllEl Ifrom his chain of command. (Exhibit: 43) Testimony provided by several other providers con?rm that this behavior is unprofessional and exceeds the boundaries which providers should use to build a therapeutic alliance with a Soldier. (Exhibits: 20. 21, 27, 23) Some of Iobjectionable comments include: A CT ?Trying to figure this guy is an exercise in futility. (Exhibits: 34, as, 43) 'l have had better people call the worse things. it is part of the job and they think because i am a civilian, because lam a female, because haven?t served that they could talk to me in a certain way.? (Exhibits: 34. 39, 4B) ?The guy has some freaking issues; why he is all freakin - hung up and concerned (nothing personal) but on as Ed with Why he has his personal energy focused into that is one of God?s own [little] mysteries" (Exhibits: 34. 39, 43) Men you are going to a job that you hate, it is going to spill out into the rest of the life, the idea is, you have already done the first thing, you have already acknowledged, 'l feel on edge, feel like a target, Heel like everyone is out to get me at work', because let's face it to a certain extent they are. don't think your immediate chain of command is quite so much as the people above them; which doesn't really help at all.? (Exhibits: 34, 39 48) 'll' CPis saying to you, 'hey dude ill were you would go to a court- martial' he could he completel on the other side of the fence. l'm not trying to stick up for him or libiisi but they are not selling you down the river the way that they could; don't think they have drank the knot-aid that not (bite) is passing out. They probably have to walk a very ?ne line because this is their boss and let?s face it, nobody wants to be on his radar but at the same time they are also saying, 'yeah if i were you i would take it to a court-inertia (Exhibits: 34, 39, 48) 10 Page 19 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations ?He role could be right in there preaching from the same hymnal that no (bile) is, and from what you are telling me he is not. Now is he going to go champion and advocate for you to the 10?" degree; No he is not, people have to be selfish; he has his own self- preservation, this may not be the battle for him to light. But he hasn?t gone to the dark side yet. (Exhibits: 38, 39, 48) 2) I also ?nd thatllbiisi Icomments to 8556 concerning his Article 15. administrative separation, and potential VA bene?ts were beyond the preper scope for a behavior health provider and, in some instances, her facts were wrong. (Exhibits: 34, 39, 48) While a BHP referring a Soldier to speak with a VA Liaison, the or TDS is perfectly appropriate, moving into the realm of giving advice in these areas goes beyond the expected scope of behavioral health care. Commenting on whether a Soldier should turn down an Article 15 and implying that he could get full VA bene?ts regardless of l?'LLQLadminiTtrative actions is misleading. (Exhibits: 34. 39. 48) Some of (We) statements that go beyond the scope of behavioral health treatment are as follows: ?The other side to this, i want you to start talking to the VA liaison. .. what i am going to tell you, is that because you have had a reenlistment, pretty much and this is not capped in stone because the VA does things and there is always moving parts which is why i want you to talk to them, to the best of my knowledge for the past 6 years as long as you have one honorable discharge you are entitled to full VA benefits, they can take you to court-martial: they can dishonorany discharge, you can do a whole bunch of stuff to conclude this chapter, but because you have a 00214 that says honorable discharge you are entitled to VA benefits.? (Exhibits: 34, 39, 48) ?You can also still be chaptered from the M58 board, so objectively, would say that this is might be a blessing in disguise, if he ?nds you retainable, you get chapter?ed, you and up with all of the bene?ts you would end up with anyway but are out of the military 18 months short, rather than have to hang around with these folks going through an MEB, still get your medical care, still get your disability rating, still get your all of that stuti: that ?s howl would look at it. You don?t have to deal with these guys at 1-3 for the next year and half. (Exhibits: 34, 39, 48) (1 Did (We) say that $86 commander ?is an asshole," that he ?has it out for you," and that ?you have a target on your back," or words to that effect? ll Page 20 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers - Findings and Recommendations Resgonse: Yes,did say that $86 commander ?is an asshole," that he ?has it out for you,? and that ?you have a target on your back.? or words to that effect. Discussion: Ilbli?l Iadmitted that she liker to Gthat his Battalion Commander was an asshole and that 886 We) had a target on his back or something similar to that. (Exhibit: 7) to SSGIWE) "We? I Msaid ?he had a target on his back" and LTC 5 it out for you". (Exhibit 5) The audio recording con?rmed that made the following statements: (Exhibit: 34) TC (WE) you and! have talked about this before) has it out for you. He has a hair across his ass. (Exhibits: 34, 39. 48) "l have talked to the man It. TC on the phone and he is an asshole; but he is also a Colonel; so he apparently gets to behave that way for whatever reason. (Exhibits: 34, 39. 43) ?There is nobody that could be in your situation, regardless of what eXperienoes they have had that would look forward to coming to work, that would be happy while they are here, that wouldn?t feel like they have a target on their back. Let?s face it you do; you have a Colonel who is out for your ass. For whatever reason; it doesn?t really matter it is what it is.? (Exhibits: 34, 39, 48) (2) Did she inform his diagnosis on 2 May 2014? Did she say that the diagnosis really ?doesn't matter," or words to that effect? Res - onse: No, (bits) id not inform SSG of diagnosis 0 (bile) 014. Yes, (W5) did say that the diagnosis really ?doesn't matter," or words to that effect. Discus? 3 Although provided a diagnosis of. W5) I when 886 asked her for his diagnosis the medi records indicate her actual diagnosis was documented as Ilbll?l I (Exhibits: 34. 39, 65) a) A review of 886 medical records of his encounters I shows a consistent diagnosis oflibli?l I (Exhibits; 63, 65I 66) Neither nor the DSM-S contain a diagnosis of ?33(5) A review of codes shows I or an application I (We) (Exhibit: 31). When SSGWIfurther asked about the diagnosis, (bile) redirected the conversation stating: r-I. 12 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations b) Imus) (bliEl Iibilsi You know what your IRather than get worked up about the diagnosis, treat the (Exhibits: 34, 39, 48) Ifailure to directly and accurately answer SSG question was not consistent with the Evans Army Community Hospital Patient Rights tenet of "be well informed about your health and care?. (Exhibit: 82) While outside the scope of this question, during my i - . - listened to several other recor as - I a tween and 386 (Exhibits: 34. 39. 47) displays similar unprofessional behavior on 12 February 2014 and 4 April 2014. On 12 February 2014. she refers to the Army as ?the machine?. (Exhibit: 34) On 4 Aril 2014, she makes multiple unprofessional comments about Sin of command. (Exhibits: 34, 39, 47) Most egregious. refers to the recent oodshooting, opining that this tra ed may prove bene?cial for 886 (We) (Exhibit: 34) find that Ilblisl Idisplayed a pattern of unprofessional behavior. (We) Iobjectionable comments on 12 February 2014 and 4 April 2014 include: ?Good news bad news is this guy just shot up Fort Hood you probably have a better standing with lG right now. They are going to put everybody from behavioral health under a fucking microscope. So, the good news for you, because of what the guy did in Texas, it you go to is and say you know they're really pushing me, they?re getting me to the point' and you check at? the stuff that you check 01? on this 00, they'll probably snap right to it because even/body's got a ?ashing hair across their ass.? (Exhibit: 34) ?7 hey have a hard-on for you? (Exhibit: 34) "You have a target on your back, don?t know why" (Exhibit: 34) ?They think you are playing a game. i know they have a really low opinion of me but i really don't care. (Exhibit: 34) ?They are going to push you until you fuck up? (Exhibit: 34) "i am not going to wait until May because they are going to keep fucking with you. (Exhibit: 34) 13 Page 21 Page 22 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers - Findings and Recommendations ?if you want to get ahead, you have to be part of the machine. And if you aren't part of the machine, you get Spit outside. You can love the Army but the Army is not going to love you back. (Exhibit: 34) ?lfyou don?t take care of yourself now, they?re never really going to. Unfortunately it is too rare for the Anny to take care of its own people. (Exhibit: 34) *3 <51 (or his representatives, (We) and (We) hmaudiaFPecordings or other evidence of encounters with MAJ Iibli?} landlibiisi If so, request a copy of the recordings or evidence. Res onse: Yes. armed that $36 - and his representatives. W5) land (We) do have audio recordings of encounters with MAJ (bli?i and The rovided copies of audio recordin all ed to be of appointments with MAJ on 23 April 2014 and 2 May 2014. (Exhibits: 6, 34, 87) I re uested a copy of all information they deemed relevant to this investigation. (bits) and (bits) i (bits) Iprovided a CD with 18 audio recordings of 19 patient encounters of 886 (we) Iwith EACH behavioral health and 1 audio recording of SSGwith this Company Commander. (Exhibit: 34) t%tscussion: (We) con?rmed that she was the BHP on the audio recording atient encounters with 386 (Exhibit: 39) LTC and (bits) confirmed that the provider on the 23 Apr 14 audio recording was MAJl?ii?LLEuhihmj 36, 37) A summary of the audio recordings with MAJ Iibli?l land We) is included in Exhibit 86. 1) Our investigative team reviewed the 18 audio recordins of 836 medil appointments that and provided on 21 June 2014. The CD contains audio recordin aile (bits) to be of the toll rs: libii?i MAJ (We) i and libiisi iiExh' its: 6, 34) In addition, ibli53 provided audio recordings of $86 visits to the ER and a conversation with his Company Commander. (Exhibits: 34, 37. 42) All audio recordings of BHPs were confirmed by the providers or a third party. (Exhibits: 40.41.42. 43, 78) Other than the four audio recordings from patient encounters with MAJ and previously discussed. we found no other recordings that caused concern for a tack of dignity and respect or unprofessionai behavior. 2) 14 Page 23 ATZF-CG SUBJECT: AR 15-6 investigation Regarding Evans Army Community Hospital Behavioral Health Providers - Findings and Recommendations did raise concerns about the standard owned] on 24 speci?cally for encounters between 386 (bits) land (We) April 2014 and between land (We) on 3 April 2014, but since the conoems involved standard of care. they were deemed outside the scope of this investigation. (Exhibit: 6) d. Doeslms} Iorlibiisi Ihave recordings or evidence of other instances of Behavioral Health providers at EACH or the Fort Carson Medical Department Activity (MEDDAC) allegedly failing to treat Soldiers with dignity and respect? If so, request a copy of the recordings or evidence. Response: Yes. I con?rmed that libii?i IorlinE} Ido have recordings or evidence of other instances of Behavioral Health providers at EACH or the Fort Carson Medical Department Activity (MEDDAC) allegedly failing to treat Soldiers with dignity and respect. I requested a cc of all information they deemed relevant to this investigation. and mseem to have other evidence to include recordings an a documentary evidence that was not provided. They had medical records that they referenced during their interview but they did not provide me with a copy of any additional paper or digital records they have. (Exhibits: 6, 34, 35) Discussion: libiisi Iandl?mi Imentioned eight cases where they allege inapproprialf active duty Soldier, SSG (We) and an evaluation on 6 March14 from (Exhibits: 6, 35) lib?) indicated the situation with sea needed immediate attention. (Exhibit: 35) determined this Soldier's case could not wait until the conclusion of my investigation. I noti?ed the appointment authority and provided the Soldier's name and information to the EACH Commander on 20 June 2014. As of 2 July 2014, SSG tbitei (bits) I it: 23) 1) and provided an audio recordin and an email summary of a patient encounter between LTC(then MAJ and SGT from 2012. (Exhibit: 34) The contents of this audio recordin and the email raised concerns about the standard of care provided to SGT during this patient encounter. (Exhibit: 34 The audio recordins did not raise any concerns about whether LTC treated SGT with dignity and respect. I determined further investigation into this matter was outside of the scope of my appointment and requested guidance from the appointment authority. I sent the email and the 15 Page 24 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations audio recording to the Deputy Surgeon General so that a Quality Assurance investigation pursuant to AR 40-68 could a - 'nitiated. This recording is summarized i and statement. (Exhibit: 6) 2) libli?i land lime) I provided the names and telephone numbers for the following Soldiers and indicated these cases are instances where Soldiers were not provided appropriate behavioral healthcare at EACH and recommended a review of their cases. (Exhibits: 6, 35) Since these Soldiers are no longer on active duty and the allegations deal with standard of care, i determined a review of these cases is outside of the scope of my investigation. ?331(5) (W5) e. Are Behavioral Health providers at Carson MEDDAC biased or otherwise in?uenced, coerced or pressured by leaders at EACHIMEDDAC or leaders at Soldiers? units to administratively clear Soldiers to undergo administrative separation for misconduct? 16 Page 25 ATZF-CG SUBJECT: AR 156 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations Response: ?nd that the preponderance of the evidence shows that BHPs at Carson are not biased, coerced, or otherwise in?uenced to administratively clear Soldiers to undergo administrative separation for misconduct. However. BHPs do perceive varying forms of pressure from multiple sources. to include: unit chain of command. MEDCOM. and external sources. (Exhibits: 7. 9. 10. 11. 13. 14. 15. 17. 18. 19. 20. 21, 23. 25. 27.28) BHPs do not perceive pressure from leaders; they indicated that they only received support from within EACH. (Exhibits: 7. 9. 10, 13. 14. 16. 17. 18. 20. 23. 28) Discussion: Pressure from unit chain of command. A majority of the EACHIMEDDAC BHPs noted perceptions of pressure from unit leaders. Providers report varying manifestations of this perceived pressure. to include phone calls from unit leaders. visits from First Sergeants. and one provider recounted being yelled at about policies which prevented Soldiers from being cleared. (Exhibits: 7. 13. 20) While a few providers and the Fort Carson Ombudsman perceived units were pressuring BHPs to administratively separate Soldiers. a majority of providers perceived a ressure to expedite resolution. (ExhibitsCommander. iri?dicated leaders in his command contact behavioral health providers to ensure tEiEy understand the way forward for Soldiers. but denied that they attempted to pressure providers into a particular outcome. (Exhibit: 12) It is important to note that providers stated that. while they perceived pressure. they feel confident in their supervisory support and their own professional integrity to not have the chain of command bias or coerce their clinical decisions. (Exhibits 7, 9. 13. 17, 18. 19.23. 28) Pressure from MEDCOM. I ?nd that BHPs at EACH feel an inverse pressure to ?not clear Soldiers for administrative separation even when their diagnosis does not support it". (Exhibits: 10. 17. 20. 23) Several providers noted that they felt that MEDCOM policies pressured them to either diagnose PTSD or not administratively clear Soldiers due to either policies or perceived professional repercussions. (Exhibits: 10. 11. 14. 15. 17.) Both WRMC and MEDCOM staff noted that the perception exists and are aware of the criticisms but cited that this is an education shortfall on what the policies actually say versus the interpretation that is made by some providers. (Exhibits: 21. 25. 27) Pressure External Sources. ?nd that there is also evidence to show that BHPs at EACH are afraid of negative media andior leaders second guessing their clinical diagnosis. Exhibits: 10. 14. 17. 20, 23) Several providers indicated and have created an environment of fear because of the 17 Page 26 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers - Findings and Recommendations potential negative media and, in one instance, they reported a provider to her licensure board. (Exhibits: 14, 17, 20, 23) Several providers indicated they have purchased supplemental medical malpractice insurance because of the environment at Fort Carson. (Exhibits: 14, 20. 23) Some providers feel pressure not to administratively clear soldiers in order to avoid professional repercussions. (Exhibits: 10, 14, 17, 20, 23) Were concerns about the quality of the behavioral health evaluation on 23 April 2014 raised to Carson MEDDAC leaders? It so. were appropriate and timely actions taken? Resgonse: Yes, I ?nd that concerns about the quality of the behavioral health evaluation on2014 were raised to Carson MEDDAC leaders after OTSG staff were noti?ed. Appropriate actions were taken by EACH leadership after receiving relevant information. (Exhibit: 4) Discussion: Carson MEDDAC leaders were ?rst informed of the concerns of the quality of the 23 April 2014 behavioral health evaluation in a 13 May 2014 email between EACH, WRMC and OTSG. (Exhibits: 4, 11, 57) Once they were informed of concerns about the - uaiity of the evaluation, the EACH Commander immediately directed COL the Deputy Commander for Clinical Services (DOCS) and Acting Chief of Behavioral Health, to coordinate a repeat evaluation of SSGibits: 11, 15, 23) This reevaluation occurred on 21 May 14 by and resulted in SSGIibliEi Ibeing referred to the WTU and being foundw I (Exhibits: 16, 59) 1) The EACH Commander was previously made aware of concerns about 886 behavioral health care on 5 May 2014 by but at that time no issues were raised about i - - 2014 evaluation. (Exhibit: 55) Based on a 5 May 2014 email from to the EACH Commander. the EACH Commander directed the 0008 to assess SSG liblisi Ipotential for WTU admission, need for a referral, and to ensure SSG (We) received a copy of his medical records. (Exhibits: 11, 15) stated that, in his view, afterlibiisi got involved on 13 May 14. SSG so was handled properly. (Exhibit: 6) The salient actions and associated dates concerning the appropriateness and timeliness of actions taken follows: 10 Apr 14: in Washington Dc who relays to OTSG about concerns of Ibeing in a toxic environment and becoming unstable. (ExhibitsX0) noti?es COL Lemaster telephonically that SSG 13 Page 27 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations threatening his (300. (Exhibits: 11, 29) COL Lemaster noti?es COL Commander) who directs his chain of command to bring 886 the EACH ER for evaluation. (Exhibits: 4, 6, 11, 51) 10-12 Apr 14: SSG is taken to the ER for two visits based on allegations of potentially making a threat against chain of command or other senior of?cer. He is cleared both times and released on his own. He is only evaluated by BH on the second visit. (Exhibit: 67) There is no indication of issues with SSGbehavioral healthcare at this point. (Exhibits: 4, 11) 24 A - 14: COL Lemaster receives an email forwarded from TSG from Mexmessing concerns about BH care at Fort Carson. (Exhibits: 4, 6, 54) 26 Apr 14: COL Lemaster begins coordinating with Fort Carson leadership to anange a meeting withlibiiei landlibii?i I (Exhibits: 4, 11) 28 Apr 14: COL Lemaster oontactsto set up a meeting. (Exhibit 4, 6, 11. 53) 1 14: COL Lemaster meets with I?m land libiisi I at the Mountain Post Medical Home. The discussion focuses on USJAG's access to Fort Carson, prior cases, and they do discuss concerns about a current case that if not addressed could result in a bad outcome but do not name the Soidier. 8863 not identi?ed at this meeting. (Exhibits: 4, 6, 11) 5 May 14: (We) emails COL Lemaster and identifies the unnamed Soldi as 886 w, COL Lemaster directs COto review SSG for potential WTU admission. assist in getting SSGhis medical records, and review his case for a potential referral. (ExhibitsMay 14: Imus) Imeets withlibiiei I nd pla ta mlpatient encounters between MAJ (We) and (We) I (Exhibits: 4, 25) 12 Ma 14: speaks with (We) and discussed the case. noti?es LTCIibii?i and LTC about the recorded 19 Page 28 ATZF-CG SUBJECT: AR 15?6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations patient interview. LTC calls COL Lemaster and noti?es him of the alleged recordings. (Exhibitsnoti?es LTC - via email of the audio tapes and tly noti?es orsc Leadership. COL We) We) COL Lemaster. and LTC (bite) about the recorded patient interview. COL Lemaster directs COL (We) to reset the BH evaluation. do a quality review oflfbiisi land MAJ and reiterates his prior guidance about consideration for WTU and (Exhibitsreferral to the for initiated. (Exhibitsreevaluated (Exhibitsaccepted into the Fort Carson wru. (Exhibits: 4. 11) 1W5) on actions taken in SSG case and they further discuss concern with EACH BH. reports that he has an 1 reco After the call. COL Lemaster places MAJ We) . and in abeyance and initiates an AR 40-68 investigation. (ExhibitsJun 14: COL Lemaster meets withl?biisi I and at Mountain Post Medical Home. (bits) rais as concerns about several other cases to include SSGIibiisi I libil?i plays an audio recording I - - ter of wire - .- rted to be a 2 May 14 encounter between (We) and SSG He also reports that they have an audio :ape c: a from 2012 which they are currently havin transcribed. Upon return from the meetin. COL Lemaster directs COL to review the speci?c cases raised by (Exhibits: 4. 6. 11) 9 Jun 14: T36 appoints an AR 15-6 investigation. (Exhibits: 1. 4) 30 May 14: COL Lemaster conducts a telephone call withlibiisi meeting. Durin the call, COL Lemaster update 12 June 14: COL Lemaster is noti?ed of a 15-6 that will review BH care at Fort Carson. COL Lemaster initiates a ?ag on MAJ (Exhibits: 4. 11) 20 Page 29 ATZF-CG SUBJECT: AR 15?6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations 9. Additional Findings. (1) MAJleadership and communication style consistently were described as ?gruff?. direct. and lacking diplomacy by his subordinates. fellow BHPs. and superiors. (Exhibits: 9. 10. 13. 14. 15. 17. 18. 20. 23) Afew BHPs reported patient complaints about his gruff. crass. and co - I . ?onal manner. (Exhibits: 9. 13. 20) Additionally. his ?rst-line supervisor. LTC indicated that MAJ {bits} ?gruff? communication style was long-standing: have known him for years. Very clinically competent. He does his due diligence. He needs to work on his delivery of bad news. His personality is more like a surgeon as he has a tendenc to be gruff.? (Exhibit: 10) The EACH DCCS provided a like assessment of MAJ {bits} I ?Prior to SSG issue. I had limited interaction and no negative feedback. He has a gruff mannerism. My personal opinion is that he has a sureon-like personality but works in (Exhibit: 15) Apart from LTC mention of having counseled him on his I found no evidence of any attempt by a leader or peer of MAJ at EACH to effectively address his shortcomings in communicating with staff and patients. (Exhibit: 10) (2) There is a widespread perception among EACH BHPs of behavioral health staf?ng de?ciencies which doesn?t comport with WRMC or OTSG views of manning. (Exhibits: 75. 76. 90. 91. 92. 93.94) (3) No policy standardizing reevaluations for command directed behavioral health evaluations. (Exhibits: 7. 9. 10. 13. 14. 16. 17. 18. 20. 23) never received notice of administrative separation IAW AR 635-200: however. his BHPs were led to believe he was pending administrative searation. This disconnect contributed to the confusion in communication between 886 and his BHPs. (Exhibits: 80. 89) This is further complicated by the removal of a waiting period or a standardized document for requesting command directed behavioral health evaluations for Soldiers pending administrative separation. (Exhibits: 33. 50) 4 The administrative separation on SSG was never formally initiated. sse An EACH BHP subsequently reported a recommended case for review (SGT (We) . This Soldier. who is now separated from the Army. was denied access into due to ongoing chapter action on 30 Apr 14. (Exhibit: 79) (6) The Ombudsman is disenfranchised which may inhibit timely and effective resolution of behavioral health patient concerns. (Exhibit: 19) (7) Multiple providers stated that they felt that the Embedded Behavioral Health program was "value added" but did cite concerns that they were isolated with limited 21 Page 30 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations connections and communication with other medical and behavioral health teams which they felt did increase the risk for pressure from Commanders. (Exhibits: 7, 13, 14, 17, 18. 20, 21, 23, 25) (8) We} and (bus) Ihighlighted several discrepancies between audio recordings of SSG limit? encounters and what was documented in the medical records. For example, MAJ (W5) evaluation was 34 minutes; however he documented 60 minutes in he medical records. (Exhibits: 6. 34,64). The Fort Carson ombudsman also reported patient complaints concerning medical record accuracy. (Exhibits: 19, 35) (9) i was impressed by the professionalism and dedication of the majority of EACH BHPs interviewed. 4. Recommendations. a. MAJ (are, Embedded Behavioral Health) (?ibiiei (bits) (more: (bite) (3)ibii5) (bile) b. (his) (Social Worker, seen) (nihii?l (bills) (2) (hire) (bills) 22 Page 31 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations (bii?i (1) (bits) (bits) (2) (bits) (bits) d. MEDCOMIEACH: (1) Recommend the MEDCOM Commander conduct a site visit at EACH speci?cally to discuss the issues documented in this investigation and conduct a sensing session for BHP staff at EACH. Recommend reinforcing the intent of MEDCOM Policy 12?035. (2) Recommend MEDCOM revise MEDCOM Regulation 40-38 to address the lack of consistency concerning how second opinions for mental health evaluations are assigned and provide guidance on handling complex cases. In the interim, recommend EACH publish a local policy addressing how second opinions for mental health evaluations are assigned and provide guidance on handling complex cases. Recommend EACH consider how to more ef?ciently use providers with quali?cations to conduct mental status evaluations for administrative separations. (3) Recommend EACH conduct a Behavioral Health stand?down day to address issues of professionalism in the workplace; dignity and respect during patient encounters; the use of profanity during patient encounters; how to handle pressure from the chain of command; how to appropriately align with patients; proper boundaries for discussions with patients concerning bene?ts and the administrative separations; and the danger of focusing on outcomes during patient encounters are reviewed and discussed among all BH professionals on Fort Carson. (4) Recommend EACH review the current use of the ombudsman at Fort Carson. Recommend the ombudsman work in the hospital and have direct access to the hospital chain of command to ensure patients have a venue for elevating ccncems to the hospital leadership. 23 Page 32 ATZF-CG SUBJECT: AR 15-6 Investigation Regarding Evans Army Community Hospital Behavioral Health Providers Findings and Recommendations (5) Recommend EACH Commander institute a system which reestablishes collaboration with patient advocates. (6) Recommend MEDCOM conduct annual retraining concerning MEDCOM Policy 12-035 to ensure new hires are aware and understand the policy and ensure current employees are kept current on the policy and the intent. (7) Recommend MEDCOM conduct a review of the cases listed in and to ensure the BHPs met the standard of care in each of those cases. (8) Recommend EACH develop an Information Paper for patients explaining the options they have if they have concerns about a BHP. The Information paper shoutd be provided to the ombudsman and be prominently diaplayed at all EACH behavioral health clinics. (9) Recommend EACH conduct a holistic review of BH manning to ensure the most ef?cient use of available resources and address the issues with workload. (10} libiif?i (ME) 5. Point of Contact for this action is the undersigned atl?ibiisi I Alternate POC LTC (We) let (bit?i and libitsi at (bite) JOHN P. SULLIVAN Brigadier General. US Army Investigating Of?cer 24