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ASHEVILLE VA HOSPITAL HAD SEVERE CARE ISSUES --
After inquiry, federal officials told center to
stop
admitting patients to its nursing home.
Asheville VA
Story here...
http://www.charlotteobserver.com/
112/story/67153.html
Story below:
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Asheville VA hospital had severe care issues
After inquiry, federal officials told center to
stop admitting patients to its nursing home
STELLA M. HOPKINS
shopkins@charlotteobserver.com
Federal officials told the Asheville veterans hospital to stop admitting
patients to its nursing home in late 2004 after investigators found
serious care problems.
VA investigators said that a patient died after an untrained worker
removed fluid from his abdomen, according to a report obtained by the
Observer.
Investigators also concluded that hospital workers didn't give enough
pain medicine to seriously ill patients. They cited the case of an
elderly man who said he suffered the "worst imaginable pain" at least
seven times in the week before he died.
They said workers made "questionable use of restraints" and didn't
understand how to care for dying people, the report said.
This is the second N.C. veterans hospital at which the Observer has
uncovered problems with patient care, including deaths.
The Veterans Affairs Department told the Asheville hospital to
temporarily stop admitting patients in its 120-bed nursing home unit,
the focus of the December 2004 investigation. The hospital suspended
admissions and made other changes, said a VA spokeswoman.
"The incidents are disturbing," Adrien Creecy-Starks, with the VA in
Washington, D.C., said in an e-mail Wednesday.
The hospital's response included hiring more people and increasing
training, she said. She didn't know how long admissions were suspended,
whether the hospital fired anyone and whether investigators have closed
the case.
Observer stories about poor care at the Salisbury veterans hospital have
prompted a congressional hearing planned for mid-April. Salisbury is the
main hospital for Charlotte-area veterans, but some go to Asheville in
the Western North Carolina mountains.
Many VA hospitals, including Salisbury and Asheville, have nursing homes
or other facilities to care for elderly and chronically ill veterans.
Focus was on 4 cases
The Asheville case began on Nov. 30, 2004, when an employee in the
nursing home unit called the VA Office of the Medical Inspector,
expressing concern. The office quickly reviewed medical records and
"found potentially serious patient care issues." A week later,
investigators began a four-day inspection.On Dec. 17, 2004, VA officials
told the hospital to stop admissions.
The investigators focused on four cases:
• A 73-year-old veteran died in 2004 following a procedure to remove
fluid in his abdomen. Nurses' notes included, "His diaper wet with
bright red blood." He died soon after. The man was seriously ill and
death was expected, investigators said. They also said the procedure is
often appropriate, but was a mistake in this case because the man's
blood pressure was very low.
Investigators said there was no documentation that the physician
assistant was adequately trained to do the procedure. They also said
there was no evidence he had been "appropriately supervised."
• A blind 86-year-old veteran with cancer and depression may have been
improperly restrained and not given enough pain medication.
• A 65-year-old man receiving hospice care for alcoholic liver disease
said he was in very bad pain before dying. And an 80-year-old man with
cancer complained of terrible pain in the week before dying.
Investigators said patient care is supposed to include assessing and
treating patients' pain and that the Asheville VA home "does not appear
to be compliant" with such policies.
They also said the hospital's nursing home provided poor hospice care.
And they cited poor leadership and friction between managers and among
staff.
On heels of Salisbury findings
The attention to VA health care follows emotional congressional hearings
this month about deplorable conditions for wounded soldiers at Walter
Reed Army Medical Center in Washington, D.C. Army hospitals are not part
of the VA system, which provides health care for millions of veterans.
The Observer has reported that a 2005 investigation found two veterans
who died at the Salisbury VA hospital had received poor care. Another
review last year found other problems with care.
In response, three N.C. members of Congress asked lawmakers to
investigate the Salisbury VA with the same intensity focused on problems
at Walter Reed. U.S. Rep. Bob Filner, the California Democrat who chairs
the House VA committee, agreed.
Filner has questioned whether there was adequate follow-up in Salisbury
after the 2005 investigation. He also has said it is "ridiculous" that a
second team of inspectors last year didn't know about the earlier
investigation. A similar routine inspection of the Asheville hospital 10
months later makes no reference to the earlier findings.
Filner also is critical of the VA for not making the medical inspector
reports widely available. The Observer obtained the reports through
Freedom of Information requests.
-- STAFF WRITER MIKE DRUMMOND CONTRIBUTED.
-- Stella M. Hopkins: 704-358-5173
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Larry Scott --
