The Denver Post
In 2021, an employee with the Department of Veterans Affairs in Aurora alerted leadership to a troubling practice within the federal agency’s Eastern Colorado Health Care System, a vast network providing services for 100,000 veterans.
The whistleblower worked for the Prosthetic and Sensory Aids Service, which supplies military veterans with artificial limbs, wheelchairs, surgical implants, glasses, hearing aids and other devices to help them live more functional lives.
Many veterans, however, weren’t getting these services for up to a year — or at all, the whistleblower alleged. That’s because the head of the prosthetics department, Norma Mestas, was directing staff to delete orders as if they had never come in, three former employees who worked in the department told The Denver Post. The motive, they said: reduce wait times and backlogs to make it look as though the department was operating smoothly.
The orders, up to 2,500 at one point, would remain untouched for months, the employees said. Some vets in the end would never get their devices, they alleged.
“I have seen (the prosthetics) service go from broken to highly functioning under our former chief to almost immediately start to crumble and end up where we are today, broken worse than I could have ever imagined,” the whistleblower wrote to VA leadership in an April 2022 follow-up email reviewed by The Post.
This individual, whom The Post agreed not to identify out of concerns about retaliation, said they had raised the issue for more than a year and nothing had been done. Patient care used to be a priority for the eastern Colorado VA, this person wrote to the system’s now-regional director, Sunaina Kumar-Giebel.
But not anymore, the whistleblower wrote: “The veterans that our service serves are suffering and there is the potential for serious health implications or even veteran deaths that could result due to this service’s negligence.”
Last month, VA leaders reassigned the Aurora-based Eastern Colorado Health Care System’s director, Michael Kilmer, and his chief of staff over concerns about “operational oversight, organizational health and workplace culture.” Recent developments, the VA told staff in an email, prompted referrals to federal oversight agencies tasked with investigating these unspecified issues.
The VA has not publicly outlined the problems that prompted the leadership changes in Aurora, but interviews with a dozen current and former nurses, doctors, administrators and high-ranking members of leadership paint the picture of a hostile work environment and a culture of fear among its 4,000-person eastern Colorado workforce.
Workers described to The Post a culture that discourages dissent. Those who report concerns about staffing or improper behavior immediately earn targets on their backs, employees said. The human resources department is weaponized to force out individuals who speak up, they said, leading to high turnover and a staff reticent to bring up problems for fear of having their careers ruined.
Multiple Black employees said they experienced racism in the VA here, including one who settled a discrimination case after being called a monkey by a section chief.
“The employees are all unhappy,” said Sandra Baker, a retired ER physician in Aurora who sued the VA last year after she said she was forced out of her job after 32 years. “There’s no way for you to be able to speak up without being harassed or axed — you just have to take it. That place is not run by people who have any idea what’s going on in the trenches.”
Kilmer declined to comment when contacted by The Post. Mestas did not respond to messages seeking an interview. The VA declined interview requests for this story and did not answer a list of detailed questions about alleged misdeeds. Kayla Giuliano, a department spokesperson, said in a statement that the agency would not comment on internal personnel actions, but that it “takes allegations of discriminatory or improper behavior seriously.”
“You’re breaking the law”
Kilmer assumed the mantle of the eastern Colorado VA system in September 2019 after two-plus years running the VA in Grand Junction. His job purview included managing the gleaming $2 billion Rocky Mountain Regional VA Medical Center in Aurora that had opened just a year prior, along with 11 outpatient facilities spread across the Eastern Plains and San Luis Valley.
The network has a budget of nearly $1 billion and leadership oversees 300 physicians and nearly 800 registered nurses.
As a member of the Coast Guard earlier in his career, Kilmer stood on the verge of becoming an officer when he disclosed to supervisors that he was gay.
Instead of a promotion, the 32-year-old was forced out of the service in 2002, Kilmer said in an interview last year. Soon after, he founded American Veterans for Equal Rights, a nonprofit dedicated to equitable treatment for all members of the U.S. armed forces. Over time, he rose through the VA system’s ranks.
“If someone has raised their right hand and given the oath to serve,” Kilmer told the University of Washington Magazine, “then we owe them support and services when they return.”
Current and former staff, though, say Kilmer’s focus appeared more centered on optics than veteran-centric care.
“I realized I was no longer working for someone striving to be at the top,” said Lee Parmley, who served as Kilmer’s chief of staff until last year. “We were trying not to fall off the bottom rung of the ladder. It was really that bad.”
Nowhere was that more evident than in the prosthetics division, former employees said.
Here’s how it’s supposed to work: Veterans go to their doctors, who then enter what’s known as a “consult” into the system for services to be rendered. This might include home modifications so a paraplegic could get into their car or house, or orders for custom braces and orthotics.
More than 55% of individuals treated this year across the Veterans Health Administration nationwide received prosthetic care, according to the VA’s website, accounting for 21.7 million items, devices and services.
“These dedicated professionals ensure that our veterans have the essential devices needed to improve their overall well-being and quality of life within the comforts of their homes,” the website states.
Mestas became chief of prosthetics in 2021 after spending three years as an executive assistant under Kilmer in Grand Junction, according to her LinkedIn profile.
Current and former workers said Mestas appeared overwhelmed by the job. Quickly the backlog for prosthetics grew.
In November 2021, an employee emailed Mestas’ boss, David Yarbrough, telling him the department had more than 2,000 open consults — half of which were delayed.
“I have never seen the numbers this bad and I do not see them getting better anytime soon,” the worker wrote in an email reviewed by The Post, saying they had “begged for help” since May. “The thought of not taking care of veterans keeps me up at night.”
Mestas had incentives to keep the backlog in check, staff said: As soon as a consult entered the VA system, the clock started ticking. Longer times to complete consults meant worse metrics and a black eye on the department.
So the chief directed newer, lower-level employees to delete consults before ever contacting veterans, the three former department workers told The Post. VA policy mandates staff make at least two attempts within three weeks to contact the individual seeking services. If they don’t respond, staff can close the consult.
But that wasn’t happening.
“I started telling folks, ‘I know your boss is telling you to close these consults, but I’m telling you that this is illegal,’” one former employee told The Post, speaking on the condition of anonymity because they still receive VA benefits and fear retaliation. “‘These are federal policies. You’re breaking the law.’”
When veterans don’t hear anything, they go back to their doctors. The doctor looks at their file, never seeing that the consult was deleted. So they put in another consult — which might get canceled again, the VA workers said. Some veterans just give up, they said, while others pay out of pocket for the equipment.
Electronic signatures in the system show who’s closing these orders. Mestas’ own name appeared on some entries, the former employee said.
“The doctor doesn’t think the prosthetic chief is closing the consults so the vet looks bad and it creates animosity within the VA environment,” the employee said. “Now the vet doesn’t trust the system. It’s perpetual.”
Other unfilled orders would sit in an off-the-books folder and never even be entered into the VA’s official tracking system, multiple employees told The Post. This, in essence, created an illegal, unofficial waitlist that wouldn’t count against the department’s metrics.
The staffer said they saw consults for terminally ill veterans waiting for mobility items to make their final weeks or months more bearable. Those people, this individual said, never got those items before their death.
“I can’t think of anything more disgraceful and heartbreaking,” said another employee who witnessed these actions, speaking on the condition of anonymity because they still work for the VA. “That’s the sole thing the VA is built for — to take care of this population of people who made extraordinary sacrifices. This how is how they’re being treated.”
Emails reviewed by The Post show employees raised concerns about the consults to leadership as early as 2021. In an April 2022 email, one employee told higher-ups that Mestas was either “deliberately trying to hurt the service for whatever reason, or does not have the knowledge and experience to effectively run this service.”
“Either way, the veterans are suffering as a result,” this person wrote.
A regional prosthetic official, Daniel Gnatz, in a reply email, acknowledged that he wasn’t sure where Mestas “is getting her direction from or what she is thinking.”
But a year-and-a-half later, employees said the consult management practice continued. Mestas, though, appears to no longer be with the department, according to staff members. She did not answer calls from The Post and the VA would not comment on her job status.
Mestas, on her email signature, includes a quote from Jocko Willink, a retired U.S. Navy SEAL officer: “There are no bad teams, only bad leaders.”
“No one is to say a thing”
Problems inside the VA under Kilmer didn’t stop at the prosthetic department’s doors.
During the early rollout of the COVID-19 vaccine, the VA in Aurora received a batch of doses. Staff put them in a freezer, but someone forgot to shut the door, the current employee said. As a result, hundreds or even thousands of doses defrosted overnight, the employee said.
With the clock ticking on using these doses, most ended up going to hospital staff instead of the older veterans, this person said.
Kilmer, during a meeting with leadership, said they would be filing a report with the regional office saying the freezer broke, not that someone left it open, the employee said.
“He said, ‘We’re not going to report this,’” the staffer, who took part in the meeting, said. “‘No one is to say a thing.’”
The fully functional freezer, after the incident, was put in the VA basement near the service elevator to collect dust, the employee said.
The employee who witnessed the meeting filed a report with the VA’s Office of Inspector General. They said they were never contacted. Several individuals discussed reporting it up the chain of command but feared retribution.
“If you value your career at all,” the employee said, “you know there’s gonna be repercussions for saying things.”
Fear of retribution
The theme of employees fearing reprisal for reporting misconduct or other issues was pervasive among the dozen current and former VA workers who spoke with The Post.
Dr. Ronald Robinson learned this firsthand while serving as deputy chief of staff under Kilmer from 2020 until last year.
In December 2021, they sounded the alarm over a critical shortage of practitioners on the VA’s primary care team.
In a memo to leadership reviewed by The Post, Robinson said the department had 22 vacancies for licensed independent practitioners out of 119 positions — or 18% of the jobs unfilled. One Colorado clinic was down nine people. As a result, Robinson wrote, the VA would be faced with transferring more than 2,000 veterans from this clinic to community providers or increasing the caseloads of other providers.
“That was the start of the end for me,” Robinson said in an interview.
The chief medical officer at the regional level convened a meeting in Denver after the memo, Robinson said, yelling and threatening to take over the service.
The physician filed a complaint with the VA’s Office of Accountability and Whistleblower Protection — a move Robinson later called a huge mistake.
“I was sadly naive,” they said. “That just painted a huge target on me.”
Robinson ended up being fired for not filling out a timesheet correctly, they said, along with not watching certain training videos for driving a government vehicle. Their first day of unemployment? Veteran’s Day 2022.
“You just sweep the problem under the rug by firing the person,” they said. “That was their mode of operating.”
Multiple VA employees told The Post that leadership attempted to force them out the door by making their lives miserable.
Baker, the retired ER doctor, said she was reassigned in 2019 to a storage room filled with boxes that didn’t have connectivity for a computer or phone. It was punishment, she said, for filing complaints over sexist working conditions under her male supervisor. The VA even manipulated records to make it appear Baker was incompetent, she alleged in a lawsuit filed against the VA last year. An appeals board ruled in her favor.
From June through December, Baker read books, checked out bathrooms on other floors and chatted with cafeteria workers.
“What a waste of government resources,” she said. “I’m an experienced ER doctor and I’m just sitting there.”
Parmley, the former chief of staff, said internal investigations served as a way for leadership to remove people from their positions.
“It was quite a vindictive place,” he said.
A Black employee filed eight complaints over discrimination, disparate treatment, poor hiring practices and whistleblower violations. In May, the individual was stripped of all his responsibilities, he said. Now he sits at home, responding to a few emails, but otherwise “I don’t do (expletive),” he said, speaking on the condition of anonymity for fear of additional retribution.
“The VA hospital here does more to not do work than to do work,” he said.
This incident marked one of several racist allegations raised by employees at the Aurora facility.
One employee said he overheard Mestas, the prosthetics chief, call a Black employee a “dirty N-word,” according to a memo reviewed by The Post. The department found the claim to be unsubstantiated — though the employee who reported it said in an email that he was never asked to testify.
Garland Dotson, a Black Air Force veteran, received a settlement from the VA in August after he alleged a section chief told him “You look like a monkey,” adding motions with her arms. Dotson went public with the allegations two years ago.
On a separate occasion, Dotson said, his boss told him another VA worker stated he had “Black rage.”
“How is it possible people are getting away with this?” Dotson said in an interview. “It’s the culture Kilmer created.”
The Aurora VA’s nurses, meanwhile, have sounded the alarm for years over what they call unsafe working conditions and critically low staffing at the hospital.
In July, National Nurses United, a nationwide union representing nurses, rallied outside the hospital, demanding management address the “epidemic of violence” at the facility. Workers reported being assaulted, kicked, spit at, hit and threatened on a daily basis.
“It feels like our concerns are being dismissed,” Sharda Fornnarino, president of the nurses’ union who works at the VA, told The Post. “We feel defeated.”
Kilmer, during the outside investigation, will serve on a temporary assignment working on a project with the Boise VA in Idaho. Dr. Shilpa Rungta, his chief of staff, was temporarily reassigned to be a physician adviser to the assistant undersecretary for health for clinical services.
Both are eligible to return to their leadership posts.
Current and former employees said they hope the leadership changes stay permanent — a chance for the Aurora VA to wipe the slate clean and rebuild the culture that has long soured.
“I hope some healing can now begin,” Robinson said. “This will benefit the veterans receiving the care they need.”