Sen. Baldwin demands federal probe of Tomah VA Center over patient neglect claims

Sept. 18, 2026

WASHINGTON — U.S. Sen. Tammy Baldwin is calling on the Trump administration to launch an immediate federal investigation into the Tomah VA Medical Center following employee disclosures of severe patient care lapses, including medication delays, food choking incidents, and patient falls.

In a formal letter sent to Department of Veterans Affairs Secretary Doug Collins, the Wisconsin Democrat requested a comprehensive review of staffing levels, hospice care, provider coverage, and patient safety protocols. Baldwin also requested an independent investigation by the VA Office of the Inspector General (OIG).

The Senate oversight demand follows reports brought directly to Baldwin’s office by several Tomah VA employees outlining alarming conditions at the facility. According to the staff disclosures, inadequate staffing has contributed to pressure injuries, missed patient checks, food choking, and delays in administering comfort medications to terminally ill hospice patients.

The investigation request comes after criminal charges were filed against a former Tomah VA nurse accused of patient abuse for intentionally withholding oxygen from a veteran in hospice care, who later died.

“Veterans receiving hospice care are among the most vulnerable patients in the VA system, and they and their families should be able to trust that they will receive safe and compassionate care and be treated with dignity during the final days of their lives,” Baldwin wrote.

Baldwin pressed Secretary Collins for a detailed timeline of when VA and Tomah facility leadership first learned of the hospice abuse incident, what administrative or safety reviews were conducted, and what corrective measures were taken. She also formally notified the VA Office of Accountability and Whistleblower Protection to shield reporting employees from workplace retaliation.

The Tomah facility has spent years recovering from severe management and care failures exposed more than a decade ago. Baldwin emphasized that federal officials must prevent past failures from recurring.

“We cannot allow serious patient safety or management problems to take root again or allow that hard earned trust to erode,” Baldwin said.

Letter Sent to the Trump Administration

Below is the text of the letter sent by Sen. Tammy Baldwin to Department of Veterans Affairs Secretary Doug Collins in the Trump administration detailing her oversight demands for the Tomah VA Medical Center:

Dear Secretary Collins,

I write to express my grave concern regarding serious allegations about the treatment of veterans and conditions at the Tomah VA Medical Center. Employees at the Tomah VA contacted my office to report severe lapses in patient care at this facility. Their reports are specific and alarming. They include allegations of poor management and inadequate staffing contributing to falls, pressure injuries, food choking incidents, failures to conduct appropriate patient checks, and other adverse patient outcomes.

They also raise particularly troubling concerns about the care of hospice patients, including inadequate provider coverage and delays in ensuring that seriously ill veterans receive medications necessary for comfort and end-of-life care. Veterans receiving hospice care are among the most vulnerable patients in the VA system, and they and their families should be able to trust that they will receive safe and compassionate care and be treated with dignity during the final days of their lives.

I ask that you immediately initiate a full review of the Tomah VA Medical Center, including:

1. The adequacy of current staffing levels and provider coverage to provide safe and appropriate care;
2. The impact of staffing shortages on patient safety, including falls, pressure injuries, food choking incidents, missed patient checks, medication delays and other adverse patient outcomes;
3. The adequacy of hospice care and provider coverage, including timely access to medications and other necessary end-of-life care;
4. Recent provider departures and vacancies and their impact on patient care;
5. Facility leadership’s response to patient safety concerns raised by frontline employees, including whether those concerns were appropriately identified, addressed and corrected;
6. Whether management and leadership practices are contributing to unsafe conditions at the facility;
7. The immediate actions VA is taking to address any identified patient safety risks; and
8. The VHA and the VISN 3 officials responsible for ensuring that necessary corrective actions are implemented and sustained.

Separately, the criminal charges recently announced against a former Tomah VA nurse raise serious questions about the care of the hospice patients at the facility and how VA responded after learning of that incident. I ask that you provide my office with a full accounting of VA’s response upon learning of the alleged abuse including:

• When VA and Tomah facility leadership first became aware of the incident and what immediate steps were taken to protect other patients;
• What administrative, clinical, patient safety or management reviews were conducted;
• What deficiencies, if any, were identified;
• What corrective actions were required; and
• Whether those corrective actions were implemented and sustained.

A veteran receiving hospice care at the Tomah VA was allegedly abused and later died. A year later, employees are raising serious concerns about the safety and quality of hospice care at the same facility, in the same hospice unit. That demands close scrutiny. I ask you to determine whether there are broader failures in staffing, supervision, management, or patient safety practices, what VA learned from the 2025 incident and whether the actions taken afterward were sufficient to protect veterans from similar harm.

I am copying OAWP on this letter so that it is formally aware of these disclosures and prepared to respond promptly to any allegation of retaliation or reprisal. I also ask that OAWP work with my office to ensure employees who have raised concerns understand their rights and the confidential reporting channels available to them.

The Tomah VA and the veterans it serves have spent years working to rectify and recover from the serious failures uncovered at the facility more than a decade ago. VA employees, veterans and the surrounding community worked hard to improve care, strengthen accountability and rebuild trust. We cannot allow serious patient safety or management problems to take root again or allow that hard earned trust to erode. Veterans and their families must be able to trust that VA will provide the safe, timely and high-quality care they have earned. Employees must also be able to raise concerns when that standard is not being met and know that speaking up will not put their careers at risk.

I ask for your prompt attention to these matters and a written response detailing the immediate actions VA is taking at the Tomah VA, providing the requested accounting of VA’s response following the August 2025 incident, the steps being taken to protect employees who raise concerns and the senior VA officials responsible for overseeing this response.