VA inspection reveals patient develops ulcer, loses wheelchair during Augusta stay

Poor patient care and lapses in communication between facility staffers led to a veteran developing a pressure ulcer and losing his wallet and motorized wheelchair during his stay last year at the Charlie Nor­wood VA Medical Center in Au­gusta, according to an inspector general’s report released this week.


The report, issued Wednesday, comes less than three months after hospital Director Robert Hamilton revealed that delays in more than 5,000 diagnostic, screening and surveillance endoscopies led to three cancer-related deaths.

The latest report does not link any issues to fatalities but does state that the veteran, who was in his 60s but not identified, visited the hospital in April for a leg amputation and left 80 days later for a hospital in Alabama with a pressure ulcer on his tailbone that could not be classified for diagnostic purposes.

The Department of Veterans Af­fairs’ inspector general office, which visited the Augusta VA on Aug. 12, discovered through interviews and medical records that staffers and physicians provided “neither accurate nor sufficient information” about the patient’s treatment and “failed to properly document, track and protect” his personal belongings, the report states.

Pete Scovill, a spokesman for the Augusta VA, said Thursday that hospital administrators are closely reviewing the inspector’s report and that it is part of an open, continuing process the medical center uses to improve its service to veterans.

Regional officials and leaders at the hospital agreed that the problems identified in the 17-page report occurred, and they responded with a three-page list of steps they plan to take to correct the issues.

By the end of February, Hamilton wrote to the inspector general, staffers will be re-educated on procedures and policy; also, reviews of admissions and discharges will be conducted regularly to ensure that belongings are secured and returned to patients.

Hamilton added that by the end of March, the facility plans to roll out a new patient-centered care initiative that places more emphasis on the engagement of staffers with patients and families throughout the facility.

Both areas of improvement are much-needed, the inspector’s reports states.

The veteran, who first raised allegations of improper care through the office of U.S. Rep. Doug Collins, R-Ga., was known to suffer from medical conditions, including chronic heart failure, kidney disease and long-standing circulation problems in his left leg.

He returned to the Au­gus­ta facility for follow-up assessments on the leg in April 2013 and was diagnosed with a plantar ulcer after being admitted to an inpatient medical unit.

The inspector general’s report states that admission notes do not include a reference to breakdown in the tailbone area, nor do they indicate that the patient was not at high risk for developing pressure ulcers.

Investigators, however, said they later found that documentation of the presence and severity of pressure ulcers – and actions taken to prevent and treat them – was inconsistent, making it
difficult to determine when and where the skin and tissue irritations developed and what was done for the patient.

Inspectors were not alone in their lack for clear information.

VA policy states that staffers may disclose certain health information, such as treatment updates, to
family members when in
the best interests of the patient.

Members of the patient’s family, however, told investigators that they were given incorrect information about whether their relative had excess fluid removed from his chest cavity two
days after his respiratory condition began to deteriorate and three weeks after his left foot and ankle were amputated.

The inspector general reported that a staff member in an interview recalled talking to the patient’s family and inadvertently giving them erroneous information about the procedure.

Investigators said they found no evidence of the family’s being notified, as requested, when the patient was transferred from intensive care to the medical unit on day 12, after a below-the knee amputation.

Inspectors said they found the facility was not aware that the patient’s motorized wheelchair had been misplaced until they brought it to its attention.

Local policy requires that health administrators list, label and place non-ambulatory patients’ belongings into an envelope for storage in a secure area. A receipt is to be placed on the patient’s chart.

“A consistent process to account for clothing items stored in the facility ‘clothing room’ was not in place,” the report stated. “Additionally, we noted that while there was a process for inventorying, documenting, labeling, and storing personal property, including money, jewelry, and other valuables, staff was confused as to which staff was responsible for carrying out the process.”

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Pressure ulcers are localized injuries to the skin and underlying tissue that usually occur over a bony prominence as a result of pressure or friction. The most common sites are the tailbone, heels and hips, but the elbows, knees, ankles or back of the head also may be affected.


Failure to deliver quality health care to veterans could become costly to senior executives in the Department of Veterans Affairs.



Fri, 01/19/2018 - 21:23

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