A veteran at an Indianapolis Veterans Affairs health center lost one of his feet to medical amputation because of “administrative errors,” federal investigators said Wednesday, as first reported by The Indianapolis Star.
American Legion National Commander Brett P. Reistad called it a case of “mission delayed turning into mission failure” in a statement and called for VA officials to create a plan to prevent future communication breakdowns between home-care social workers and VA medical centers.
A fumbled change in how home-care visits are scheduled for patients released from the Richard L. Roundebush VA Medical Center in Indianapolis led to a mistaken amputation of the unnamed veteran’s leg below the knee, according to a copy of an investigative report and a letter to President Donald Trump from Henry J. Kerner of the U.S. Office of Special Counsel, an independent agency that investigates whistleblower reports.
Kerner wrote to the president that three whistleblowers reported medical center employees “engaged in conduct that constitutes gross mismanagement and a substantial and specific danger to public health.”
The whistleblowers alleged that lack of sufficient planning, training and communication resulted in “significant delays in care and harm to veterans” and that medical center management told social workers not to enter home healthcare consultations into a computerized patient record system.
Kerner said in his letter that the VA medical center substantiated the whistleblowers’ allegations -- social work leadership did tell social workers to stop entering home healthcare consultations into the system “due to concern it was outside the social workers’ scope of practice.
“These actions resulted in a system breakdown” since leadership tried to make a change without collaborating with other “key services or allowing time for coordination and education.”
The change and lack of planning, training and communication led to “significant delay in at least one veteran’s care,” Kerner wrote in his letter.
In June 2017 a veteran was discharged from the VA medical center after treatment for a complication of diabetes and an ulcerated bacterial infection on his foot.
A home healthcare consultation was scheduled to help the veteran dress his foot wound at home, but it was not properly scheduled in the computerized system and help never came.
The veteran’s wound became infected and was amputated because he did not have help to change the dressing on it at home, the letter said.
The medical center has since updated its standard operating procedures surrounding home healthcare consultations and post-discharge follow ups, Kerner wrote. No one at the medical center was fired as a result of the incident or investigation, Business Insider reported.
“While I commend the VA for taking the necessary steps to prevent similar problems from occurring in the future, I am nonetheless distressed that such a situation occurred in the first place,” Kerner told the president. “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.”
Reistad said the American Legion hopes the VA took necessary steps to prevent future occurrences.
“Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice,” Reistad said. “We thank the whistleblowers who helped expose this case. It reinforces why The American Legion supported legislation that protects these brave employees. 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. 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."