A recent investigation by the Department of Veterans Affairs, which was prompted by three whistle-blowers, and a letter to President Donald Trump, written by Henry J. Kerner of the U.S. Office of Special Counsel, has revealed a botched change in the way home-care visits were scheduled beginning in 2017, which resulted in delayed care for veterans. Specifically, the investigation revealed “a system breakdown” due to the fact that “leadership attempted to implement the change without collaborating with key services or allowing time for coordination and education.”
As a result, veterans, collectively, received delayed care. However, for one veteran, who remained anonymous, the delayed care resulted in a below-the-knee amputation. This veteran was discharged from the Indianapolis VA Hospital in 2017 after receiving treatment for diabetic ketoacidosis and an ulcerated foot abscess but, according to the letter to President Trump, he “did not receive the necessary home health care” due to the delays directly attributable to the new and “unapproved” changes in home health care. The lack of care resulted in a worsening infection, leading to osteomyelitis and subsequent amputation, which was apparently related to a delay in performing dressing changes on the part of the home-care agency.
The investigation substantiated allegations that this change led to a system breakdown, as the transition was not implemented with key services in a collaborative and cohesive manner, and, aside from the delay in veterans receiving home-care, also found the following:
There was no quality assurance mechanism in place to verify whether the new practice was working;
There was a lack of nursing staff assigned to support the rollout of this pilot program, and no contingency plan to deal with staff absences; and
There was inadequate social work and nursing staff to provide appropriate and timely processing of consultation orders.
According to the report, the then-chief and assistant chief of social work services at the Indianapolis VA, who remain unnamed, are primarily to blame for the problems, which began in March of 2017, when the chief of social work services “directed that social workers should no longer enter” orders for home care into the patient record system as this process required the inclusion of medical information that is outside the scope of practice for social workers.
The report also found other cases in which care was delayed, but none involving “evidence of negative clinical outcomes such as readmission, higher levels of care, or hospitalization.” Nonetheless, investigators still determined that “the lack of coordinated care from the inpatient to outpatient setting poses a risk to public health and safety at Indianapolis.”
While it is fortunate that those other cases did not result in serious harm to the veterans, the overall failure to provide adequate and timely home-care to our veterans is shameful. As for the veteran who lost his leg, it pains me to think that after serving his country, he lost his leg not during a time of war or on the battlefield, but because of mistakes made by the agency entrusted with his care.
Since 2017, the Indianapolis VA has updated and implemented new procedures for monitoring consults and post-discharge follow-ups. However, in 2018, the facility received only three out of five stars in a Veterans Health Administration year-end rating, which noted only a small improvement from the 2017 baseline score.