Tomah VA Employee Charged With Abuse After Hospice Veteran's Oxygen Allegedly Cut, Veteran Died
By VA Headlines staff · Published November 10, 2026 · Source dated September 18, 2026 (U.S. Senate, Sen. Tammy Baldwin)
Sen. Baldwin on Sept. 18, 2026, asked VA and the Inspector General to investigate alleged care failures at Tomah VA Medical Center after employees reported lapses, and after a former Tomah VA nurse was charged with patient abuse. The official letters do not name the nurse.
What employees reported, per the official letters
The letters describe those reports as allegations. They include 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 describe concerns about hospice care, including inadequate provider coverage and delays in medications needed for comfort and end-of-life care.
What Baldwin asked VA to do
Baldwin asked the VA Office of Inspector General to conduct an independent investigation. She also asked Secretary Collins to immediately direct the Veterans Health Administration and the Veterans Integrated Service Network to conduct a full review of staffing levels, provider coverage, medication delays, hospice care, and patient safety, and wrote that the review "should not rely on assurances from leadership at the Tomah VA."
At a minimum, she asked VA to determine:
- the adequacy of current staffing levels and provider coverage to provide safe and appropriate care;
- 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;
- the adequacy of hospice care and provider coverage, including timely access to medications and other necessary end-of-life care;
- recent provider departures and vacancies and their impact on patient care;
- facility leadership's response to patient safety concerns raised by frontline employees, including whether those concerns were appropriately identified, addressed, and corrected;
- whether management and leadership practices are contributing to unsafe conditions at the facility;
- the immediate actions VA is taking to address any identified patient safety risks; and
- the VHA and VISN 3 officials responsible for ensuring that necessary corrective actions are implemented and sustained.
She asked for a prompt written response on the immediate actions VA is taking, on the August 2025 incident, on protections for employees who raise concerns, and on the senior officials responsible.
The criminal charge described in the official records
Separately, the official release and both letters state that criminal charges had been announced against a former Tomah VA nurse. The release says a Tomah VA nurse was criminally charged with patient abuse after a veteran receiving hospice treatment had oxygen allegedly withheld on purpose and later died. The letters state: "A veteran receiving hospice care at the Tomah VA was allegedly abused and later died."
The letter to the secretary refers to an August 2025 incident and asks for a full accounting of when VA and Tomah facility leadership first became aware of the alleged abuse; 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 actions were implemented and sustained.
The letters note that, a year later, employees were raising concerns about hospice care "at the same facility, in the same hospice unit." Baldwin asked whether there are broader failures in staffing, supervision, management, or patient safety practices, what VA learned from the 2025 incident, and whether later actions were sufficient to protect veterans from similar harm.
These official records do not name the nurse. This page does not either. The charge has not been adjudicated in the records cited here, and the letters do not state that the alleged abuse caused the veteran's death.
The request to the Inspector General
In a separate letter to Inspector General Mason, Baldwin asked OIG to investigate whether staffing shortages, provider shortages, management failures, or other deficiencies at the Tomah VA are jeopardizing patient safety and the quality of care. She asked OIG to examine the same core issues listed above, and asked investigators to meet directly and confidentially with frontline employees. She wrote that her office would share information, including contact information for employees who authorized it.
She also asked OIG to review how VA responded after learning of the incident involving the former nurse. She wrote that ongoing criminal proceedings may limit what OIG can share, but asked to be kept informed about the investigation and about what steps are needed to prevent a similar incident.
Retaliation, official background, and what's next
Baldwin wrote that there must be "zero tolerance" for retaliation against employees who raise patient-care concerns, make a protected disclosure, contact Congress, OIG, or the Office of Accountability and Whistleblower Protection, or cooperate with an investigation. She asked the secretary to tell Tomah employees they may use protected channels. The letter was copied to OAWP, Acting Under Secretary for Health John Figueroa, VISN 3 Network Director Dr. Dan Zomchek, and Health Service Area 3.3 Executive Director Judy Johnson-Mekota.
She also wrote that 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," and that serious problems should not take root again. That sentence refers to earlier official oversight of the same facility; it is not a finding about the 2026 allegations. A later routine OIG inspection, report 25-00216-101 (April 16, 2026), made no recommendations after an August 25–28, 2025, visit. That inspection is a separate official record.
The official records cited here are congressional requests for investigation and a written accounting. They are not a completed VA or OIG investigation, and they are not a court judgment on the criminal charge.
Related: Truman VA: nurse whistleblower case on psych admissions. Marion VA test-results patient-safety recommendations. More: all VA Headlines reports. How we report: Methodology & Corrections.
Baldwin Demands Trump Admin Immediately Investigate Tomah VA Staff Claims of Serious Failures in Care at Facility · published September 18, 2026
Read the press release
U.S. Senate, Office of Sen. Tammy Baldwin
Letter from Sen. Tammy Baldwin to VA Secretary Doug Collins · September 18, 2026
Read the letter to the secretary (PDF)
U.S. Senate, Office of Sen. Tammy Baldwin
Letter from Sen. Tammy Baldwin to VA Inspector General Cheryl L. Mason · September 18, 2026
Read the letter to the Inspector General (PDF)
U.S. Department of Veterans Affairs (facility location only)
Tomah VA Medical Center facility page
VA Office of Inspector General (separate later inspection, context only)
Healthcare Facility Inspection of the Tomah VA Health Care System in Wisconsin — Report 25-00216-101 · April 16, 2026
Read the OIG report page | Full report (PDF)
These are congressional requests and a described criminal charge, not a completed investigation or a court judgment. The official letters and release do not name the nurse. VA Headlines reports only what official records say. Spot an error? See our corrections policy.