Batavia, N.Y. (WBEN) - New York Congressman Tim Kennedy (D, NY-26) reacts to a report from the Office of Inspector General regarding the death of a veteran at the VA care facility in the City of Batavia. A report says the patient had a high blood sugar level that was not reported, contributing to the death.
The OIG's report found in late winter 2024, Resident A was admitted to the Buffalo VA Medical Center for combativeness, agitation, and confusion. After the resident’s dementia-related behaviors were controlled, the resident was admitted to the Batavia CLC, and received 21 doses of injectable antipsychotic medications throughout the 23-day stay.
On CLC Day 20, the resident’s elevated fingerstick blood sugar level was not reported to a physician for treatment. On CLC Day 23, the level was more than four times the system’s upper limit of normal.
The resident was admitted to a community hospital, then hospice at the Buffalo VAMC, and died shortly thereafter.
The OIG substantiated that ongoing and cumulative deficiencies, including physician and nursing staff management of Resident A’s dementia and diabetes and nursing documentation of medication administration and nutritional intake, may have contributed to the resident’s preventable decline in health, which necessitated end-of-life care.
The OIG found similar deficiencies in care for a second resident, and identified concerns regarding leaders’ response to clinical care deficiencies, including a failure to enter a patient safety report regarding Resident A’s elevated fingerstick blood sugar result on CLC Day 20.
Once aware of care concerns, system leaders’ response included temporarily removing the chief geriatric physician and initiation of clinical and administrative investigations.
Further, the OIG identified deficiencies in provider staffing and nurse education that increase risk to patient safety and may have contributed to Resident A’s functional decline.
Kennedy was furious after hearing the report.
"As a healthcare professional, I am appalled by the findings of the recent OIG report detailing devastating failures in care at the Batavia Community Living Center," said Kennedy in a statement Friday. "It is completely unacceptable that deficiencies in care contributed to a veteran's death and that similar issues were found with another resident. The report's findings, including preventable failures in dementia and diabetes care, poor documentation, and a lack of accountability from leadership, indicate a systemic breakdown that puts our veterans at risk. Most troublingly, these actions occurred prior to the Trump Administration’s mass layoffs at the VA, which could potentially further exacerbate the situation and put current and future Batavia residents at risk.
"As a member of the House Committee on Veterans’ Affairs, I am demanding a full review of these issues and will work to ensure that all veterans receive the highest quality of care they rightly deserve in Western New York."
The OIG issued 10 recommendations to the VA.