Improper management at the Department of Veterans Affairs office in Indianapolis led to one man having a below-the-knee amputation, federal officials said.
The U.S. Office of Special Counsel said that management at the office directed social workers to stop entering home health care consults into a computerized patient record system.
The decision was coupled without properly implementing a change. The visits weren’t properly logged.
“As a direct result, one veteran had to have his leg amputated after he was not provided timely wound care,” the Office of Special Counsel stated in a press release.
The mismanagement was brought to the office’s attention by whistleblowers.
The miscommunication led to significant delays in care, including for the vet who lost his leg.
In June 2017, the vet was discharged from the medical center after getting treatment for diabetic ketoacidosis and an ulcerated foot abscess. A home health care consult was entered to provide the vet assistance dressing his foot wound at home—but it wasn’t properly processed, so the vet didn’t get the care.
“The investigation found that the veteran’s wound became infected and required below-the-knee amputation due to the delay in receiving dressing changes from a home care agency,” the office stated.
Because of the findings, the medical center updated its consult standard operating procedures, clarifying that entering the consults are part of the social workers’ jobs. The practice of discontinuing incomplete consults was also halted. Referral nurses now immediately contact the provider or social worker to address the incomplete consult.
“It is unconscionable that after serving his country, a veteran lost his limb not on the battlefield, but because of mistakes made by the agency entrusted to take care of him,” Special Counsel Henry Kerner said in a statement. “While I commend the VA for taking the necessary steps to prevent similar problems from occurring in the future, this situation should never have happened.”
The office is an independent federal investigative agency that protects federal employees and applicants from prohibited practices, especially reprisal for whistleblowing, and provides a safe channel for allegations of wrongdoing.
An external peer review of the case is currently underway.
Kerner sent a letter (pdf) about the case to President Donald Trump, noting that while Veterans Affairs made changes in response to what happened, “I am nonetheless distressed that such a situation occurred in the first place.”
Natl Cmdr Reistad: “Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice.”
Complete statement: https://t.co/1glxHLmd4f https://t.co/xxrc5zdwzk— The American Legion (@AmericanLegion) April 11, 2019
“It is unacceptable that a situation should ever arise where our nation’s veterans are provided such substandard care that it resulted in a loss of limb because of a mistake by the agency entrusted to take care of them,” he said. “I look forward to an update from the VA upon completion of the peer review of the affected veteran’s case.”
The American Legion, the nation’s largest veterans service organization, called for the communication breakdowns to be fixed.
“The U.S. Office of Special Counsel assured the president that VA has taken the necessary steps to prevent similar problems in the future,” American Legion National Commander Brett Reistad said in a statement. “The American Legion certainly hopes that those assurances are well-founded. Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice.”
He thanked the whistleblowers that helped expose the case and said that the legion supports legislation to protect whistleblowers.
“The American Legion believes in VA. It’s why The American Legion visits VA medical facilities across the country as part of our System Worth Saving program, so we can identify critical needs and share best practices,” he added. “We will certainly review this latest incident again as part of our SWS agenda. We also believe that recent reforms such as the Mission Act and increased accountability will improve an already-strong VA system. That said, tragedies such as what happened in Indianapolis should never occur. We expect VA to learn from this and act accordingly.”