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VA hospital’s release of delirious veteran latest in string of failures

- The Washington Times - Sunday, January 5, 2014

Doctors at a Veterans Affairs hospital in Puerto Rico released a patient who was suffering from delirium and barely able to function, ignoring evaluations by staff nurses, an investigation found — the latest in a string of high-profile incidents at the department's medical facilities.

Officials discharged the man even though he could not take care of himself, was malnourished and dehydrated during his stay and required an ambulance ride to leave the hospital, according to a report by the agency's inspector general's office.

The man's family brought him home to Arizona, where he was promptly admitted to another hospital.

Mistreatment of veterans by the VA medical system has drawn harsh criticism on Capitol Hill. Rep. Jeff Miller, Florida Republican and chairman of the House Veterans Affairs Committee, leads a delegation Monday to visit centers in Columbia, S.C., and Augusta, Ga., where lawmakers say nine veterans have died because of mistakes by the VA.

A death at a Jackson, Miss., facility prompted a congressional hearing in November.

"It is painfully obvious that VA is not taking the problems occurring at this facility seriously and is showing a lack of commitment that quite apparently affects care provided to veterans," Rep. Mike Coffman, Colorado Republican, said at the hearing.

Investigators suspect as many as 21 veterans died because of mistakes and mistreatment at VA hospitals in the past year.

A December investigation by the Government Accountability Office, Congress' watchdog arm, found that hospitals in Dallas; Nashville, Tenn.; Seattle; and Augusta, Maine didn't adhere to peer-review practices, which could mean little oversight of problems or unsafe behavior by doctors.

As for the man in Puerto Rico, the inspector general said, he was admitted to the hospital for surgery in September 2012 that likely was related to his chronic liver disease brought about by alcohol abuse. During his 54-day stay, he was treated for a urinary tract infection and pneumonia.

Investigators said the man was not properly treated during his stay. He was malnourished and dehydrated and dropped from a weight of 213.9 pounds right after his surgery to 117.5 pounds. The urinary tract infection was not cured and the man's skin was covered with ulcers. Plus, he had begun to show signs of delirium.

"Nursing notes indicated the patient remained confused and combative, had visual hallucinations, and required intermittent restraints during the remainder of his hospitalization. They also noted the patient was unable to stand, perform self-care, or feed himself," the inspector general said, quoting notes written 10 days before the patient was discharged.

A social worker told the patient's family that he probably would need rehabilitation and more treatment once he left the hospital. The family traveled to Puerto Rico and flew with the man back to Arizona. He required an ambulance to transport him to the airport.

Once in Arizona, the man was admitted to a second VA hospital. The inspector general reported that he recovered and is now in a state home for veterans.

The report did not give specifics on the patient's name or service, but said he is a veteran in his 40s who moved to Puerto Rico in December 2011.

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